Provider Demographics
NPI:1356339568
Name:NIEBLES, JACQUELINE MARIA (MD)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:MARIA
Last Name:NIEBLES
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 1:1375 INDIAN TRL N
Mailing Address - Street 2:SUITE 180-S
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34683-2809
Mailing Address - Country:US
Mailing Address - Phone:727-481-8075
Mailing Address - Fax:
Practice Address - Street 1:14499 N DALE MABRY HWY
Practice Address - Street 2:SUITE 180-S
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-2078
Practice Address - Country:US
Practice Address - Phone:813-501-3710
Practice Address - Fax:813-513-9395
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-11
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME66997208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL19311OtherWELLCARE
FL255357OtherAVMED
FL26241OtherBLUE CROSS AND BLUE SHIEL
FL2840575003OtherCIGNA
DE212684OtherAMERIGROUP
FL2238087OtherAETNA
FL376077400Medicaid
FL19311OtherHEALTHEASE
FL376077400Medicaid
FL376077400Medicaid
FL376077400Medicaid