Provider Demographics
NPI:1932645033
Name:KAIN, NICOLE (RN)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:KAIN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9624 W PARK DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33626
Mailing Address - Country:US
Mailing Address - Phone:215-480-4143
Mailing Address - Fax:
Practice Address - Street 1:4002 W HORATIO ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-3939
Practice Address - Country:US
Practice Address - Phone:813-453-2217
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-12
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9322789222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL222Q00000XMedicaid