Provider Demographics
NPI:1336164276
Name:PROVOST, NICOLE (MD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:
Last Name:PROVOST
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 100371
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32610-0371
Mailing Address - Country:US
Mailing Address - Phone:352-338-2195
Mailing Address - Fax:352-338-2185
Practice Address - Street 1:3951 NW 48TH TER
Practice Address - Street 2:SUITE 101
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32606-7228
Practice Address - Country:US
Practice Address - Phone:352-265-5230
Practice Address - Fax:352-265-5231
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2013-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME65302207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL377914900Medicaid
G05209Medicare UPIN
FL27075ZMedicare ID - Type Unspecified