Provider Demographics
NPI:1700484466
Name:ROBERTSON, NICHOLE
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:
Last Name:ROBERTSON
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 1:2236 BLACKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MULBERRY
Mailing Address - State:FL
Mailing Address - Zip Code:33860-5500
Mailing Address - Country:US
Mailing Address - Phone:863-258-4147
Mailing Address - Fax:
Practice Address - Street 1:2236 BLACKWOOD DR
Practice Address - Street 2:
Practice Address - City:MULBERRY
Practice Address - State:FL
Practice Address - Zip Code:33860-5500
Practice Address - Country:US
Practice Address - Phone:863-258-4147
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-15
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-139659106S00000X
374U00000X, 376J00000X, 372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No374U00000XNursing Service Related ProvidersHome Health Aide
No376J00000XNursing Service Related ProvidersHomemaker