Healthcare Provider Details

I. General information

NPI: 1114482056
Provider Name (Legal Business Name): NIKKI RUBINSTEIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2019
Last Update Date: 10/30/2026
Certification Date: 10/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13417 US HIGHWAY 301
DADE CITY FL
33525-5446
US

IV. Provider business mailing address

PO BOX 102222
ATLANTA GA
30368-2222
US

V. Phone/Fax

Practice location:
  • Phone: 352-567-8640
  • Fax: 813-355-5027
Mailing address:
  • Phone: 239-274-8200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9114713
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: