Provider Demographics
NPI:1912401779
Name:PREMO, NICOLE DANIELLE (MD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:DANIELLE
Last Name:PREMO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:DANIELLE
Other - Last Name:ROBY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:752 TURKEY CRK
Mailing Address - Street 2:
Mailing Address - City:ALACHUA
Mailing Address - State:FL
Mailing Address - Zip Code:32615-9311
Mailing Address - Country:US
Mailing Address - Phone:720-352-4998
Mailing Address - Fax:
Practice Address - Street 1:1600 SW ARCHER RD DEPT OF
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-3003
Practice Address - Country:US
Practice Address - Phone:352-265-0077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-19
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL390200000X
FLME155371207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program