Healthcare Provider Details

I. General information

NPI: 1649232372
Provider Name (Legal Business Name): NICOLE SHUFF KENNEDY CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2006
Last Update Date: 12/15/2021
Certification Date: 12/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23450 VIA COCONUT PT
ESTERO FL
34135-1877
US

IV. Provider business mailing address

PO BOX 2147
FORT MYERS FL
33902-2147
US

V. Phone/Fax

Practice location:
  • Phone: 239-468-0150
  • Fax: 239-343-4056
Mailing address:
  • Phone: 239-424-1500
  • Fax: 239-424-1423

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN280201
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN9487918
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: