Provider Demographics
NPI:1336714815
Name:MARTIN, NICOLE (APRN)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:
Last Name:MARTIN
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 1:1382 GAYNOR CT
Mailing Address - Street 2:
Mailing Address - City:DELTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32725-5659
Mailing Address - Country:US
Mailing Address - Phone:386-956-5946
Mailing Address - Fax:
Practice Address - Street 1:3250 NE 1ST AVE APT 504
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33137-4088
Practice Address - Country:US
Practice Address - Phone:305-340-9002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-26
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11008378363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLM635630845870OtherDL NUMBER