Provider Demographics
NPI:1396479622
Name:SMITH, NIKI DEE ANN
Entity type:Individual
Prefix:
First Name:NIKI
Middle Name:DEE ANN
Last Name:SMITH
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 1:3551 SAN PABLO RD S APT 1704
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-3905
Mailing Address - Country:US
Mailing Address - Phone:904-270-9086
Mailing Address - Fax:
Practice Address - Street 1:7901 4TH ST N STE 4000
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33702-4305
Practice Address - Country:US
Practice Address - Phone:951-772-5738
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-12
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133N00000X
FLA-3628626171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach
No133N00000XDietary & Nutritional Service ProvidersNutritionist