Provider Demographics
NPI:1942856315
Name:PEREZ, NICOLE MARIE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:PEREZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16939 SW 134TH AVE
Mailing Address - Street 2:
Mailing Address - City:ARCHER
Mailing Address - State:FL
Mailing Address - Zip Code:32618-5413
Mailing Address - Country:US
Mailing Address - Phone:954-604-1304
Mailing Address - Fax:
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-5413
Practice Address - Country:US
Practice Address - Phone:352-392-4541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-12
Last Update Date:2023-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11004012363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL118033800Medicaid