Provider Demographics
NPI:1205481488
Name:EMILE, NICKLINE CLERVIL
Entity type:Individual
Prefix:
First Name:NICKLINE
Middle Name:CLERVIL
Last Name:EMILE
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 1:235 PAQUITA CIR SW
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32908-3468
Mailing Address - Country:US
Mailing Address - Phone:954-632-9694
Mailing Address - Fax:
Practice Address - Street 1:415 S WICKHAM RD
Practice Address - Street 2:
Practice Address - City:WEST MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-1137
Practice Address - Country:US
Practice Address - Phone:321-400-1220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-05
Last Update Date:2024-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11003424207Q00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine