Healthcare Provider Details

I. General information

NPI: 1235749425
Provider Name (Legal Business Name): NICOLE LHOMMEDIEU PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2020
Last Update Date: 08/03/2020
Certification Date: 08/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3850 MARNIE PL
JACKSONVILLE FL
32223-3541
US

IV. Provider business mailing address

3850 MARNIE PL
JACKSONVILLE FL
32223-3541
US

V. Phone/Fax

Practice location:
  • Phone: 631-921-7551
  • Fax:
Mailing address:
  • Phone: 631-921-7551
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9113286
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: