Provider Demographics
NPI:1972113025
Name:HORN, NICOLE (APRN)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:HORN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3507 CAPPIO DR
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-1317
Mailing Address - Country:US
Mailing Address - Phone:631-258-2410
Mailing Address - Fax:
Practice Address - Street 1:8095 SPYGLASS HILL RD STE 104
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-8290
Practice Address - Country:US
Practice Address - Phone:321-241-6400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-04
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11008036363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty