Provider Demographics
NPI:1669145611
Name:BROWN, NICOLE ANTOINETTE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:ANTOINETTE
Last Name:BROWN
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 1:13714 SIGLER ST
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33579-2324
Mailing Address - Country:US
Mailing Address - Phone:813-541-4105
Mailing Address - Fax:
Practice Address - Street 1:3301 W GANDY BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33611-2931
Practice Address - Country:US
Practice Address - Phone:813-925-1903
Practice Address - Fax:813-749-8370
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-27
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9208974163W00000X, 163WA2000X, 163WC2100X, 163WE0900X, 163WG0600X, 163WH0200X, 163WI0500X, 163WN1003X, 163WW0000X, 163WX1500X
FLAPRN11032893363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No163WA2000XNursing Service ProvidersRegistered NurseAdministrator
No163WC2100XNursing Service ProvidersRegistered NurseContinence Care
No163WE0900XNursing Service ProvidersRegistered NurseEnterostomal Therapy
No163WG0600XNursing Service ProvidersRegistered NurseGerontology
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163WI0500XNursing Service ProvidersRegistered NurseInfusion Therapy
No163WN1003XNursing Service ProvidersRegistered NurseNutrition Support
No163WW0000XNursing Service ProvidersRegistered NurseWound Care
No163WX1500XNursing Service ProvidersRegistered NurseOstomy Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL123658700Medicaid