Provider Demographics
NPI:1952760225
Name:HEETER, NICOLETTE L
Entity Type:Individual
Prefix:
First Name:NICOLETTE
Middle Name:L
Last Name:HEETER
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:PO BOX 117345
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-7345
Mailing Address - Country:US
Mailing Address - Phone:904-346-3465
Mailing Address - Fax:904-858-6489
Practice Address - Street 1:12961 N MAIN ST
Practice Address - Street 2:SUITE 201 & 202
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-2769
Practice Address - Country:US
Practice Address - Phone:904-747-2474
Practice Address - Fax:904-747-5541
Is Sole Proprietor?:No
Enumeration Date:2016-02-16
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT31155225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist