Provider Demographics
NPI:1922589050
Name:SHAFFER, NICOLETTE (OTR)
Entity Type:Individual
Prefix:
First Name:NICOLETTE
Middle Name:
Last Name:SHAFFER
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 LAKEVIEW DR W
Mailing Address - Street 2:
Mailing Address - City:ROYAL PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33411-8777
Mailing Address - Country:US
Mailing Address - Phone:561-891-7463
Mailing Address - Fax:
Practice Address - Street 1:15101 SHELL POINT BLVD
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-1694
Practice Address - Country:US
Practice Address - Phone:239-466-1131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-27
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL18654225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty