Healthcare Provider Details

I. General information

NPI: 1912467598
Provider Name (Legal Business Name): NICOLE LOUIS PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2019
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 45TH ST
MANGONIA PARK FL
33407-2413
US

IV. Provider business mailing address

3509 N BROAD ST
PHILADELPHIA PA
19140-4105
US

V. Phone/Fax

Practice location:
  • Phone: 561-844-6300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number9112025
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: