Provider Demographics
NPI:1912467598
Name:LOUIS, NICOLE (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:LOUIS
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3375 BURNS RD
Mailing Address - Street 2:SUITE 206
Mailing Address - City:PALM BEACH GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:33410-4349
Mailing Address - Country:US
Mailing Address - Phone:561-799-9559
Mailing Address - Fax:
Practice Address - Street 1:901 45TH ST
Practice Address - Street 2:
Practice Address - City:MANGONIA PARK
Practice Address - State:FL
Practice Address - Zip Code:33407-2413
Practice Address - Country:US
Practice Address - Phone:561-844-6300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-21
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9112025363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical