Provider Demographics
NPI:1861662157
Name:CLEMENTIN, NIKISHA NICOLE (MED CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:NIKISHA
Middle Name:NICOLE
Last Name:CLEMENTIN
Suffix:
Gender:F
Credentials:MED CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:435 SEDGEWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:WEST MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-8041
Mailing Address - Country:US
Mailing Address - Phone:832-315-7454
Mailing Address - Fax:
Practice Address - Street 1:2080 W EAU GALLIE BLVD STE A
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-3185
Practice Address - Country:US
Practice Address - Phone:407-694-3603
Practice Address - Fax:321-296-7130
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-03
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX103010235Z00000X
FLSA14801235Z00000X
235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty