Provider Demographics
NPI:1013469279
Name:ORTA, NIKOLE RAE (ARNP)
Entity Type:Individual
Prefix:
First Name:NIKOLE
Middle Name:RAE
Last Name:ORTA
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:NIKOLE
Other - Middle Name:RAE
Other - Last Name:BROOM-SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:PO BOX 25317
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33622-5317
Mailing Address - Country:US
Mailing Address - Phone:813-286-0033
Mailing Address - Fax:813-282-0806
Practice Address - Street 1:1344 22ND ST S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33712-2744
Practice Address - Country:US
Practice Address - Phone:727-824-8181
Practice Address - Fax:727-824-8137
Is Sole Proprietor?:No
Enumeration Date:2016-11-03
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9327079363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019680100Medicaid