Healthcare Provider Details

I. General information

NPI: 1932642311
Provider Name (Legal Business Name): NICOLE AGOSTO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2016
Last Update Date: 12/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3531 DOVETAIL AVE
KISSIMMEE FL
34741-2940
US

IV. Provider business mailing address

3531 DOVETAIL AVE
KISSIMMEE FL
34741-2940
US

V. Phone/Fax

Practice location:
  • Phone: 407-460-0234
  • Fax:
Mailing address:
  • Phone: 407-460-0234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: