Provider Demographics
NPI:1740061993
Name:ROBERTSON, NICOLE MARIE (ARNP)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 LOG SPRING WAY
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-9308
Mailing Address - Country:US
Mailing Address - Phone:904-484-6045
Mailing Address - Fax:
Practice Address - Street 1:3840 BELFORT RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-8207
Practice Address - Country:US
Practice Address - Phone:904-371-4051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-12
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11029056363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily