Provider Demographics
NPI:1649088642
Name:MENA, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MENA
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 1:5310 SW 95TH CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33165-6436
Mailing Address - Country:US
Mailing Address - Phone:305-491-4931
Mailing Address - Fax:
Practice Address - Street 1:5310 SW 95TH CT
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33165-6436
Practice Address - Country:US
Practice Address - Phone:305-491-4931
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-21
Last Update Date:2024-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11036808363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily