Healthcare Provider Details

I. General information

NPI: 1376306654
Provider Name (Legal Business Name): NICOLE LEREBOURS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2024
Last Update Date: 04/22/2026
Certification Date: 04/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8740 N KENDALL DR STE 101
MIAMI FL
33176-2209
US

IV. Provider business mailing address

4411 BEE RIDGE RD # 309
SARASOTA FL
34233-2514
US

V. Phone/Fax

Practice location:
  • Phone: 305-661-8978
  • Fax: 941-296-8501
Mailing address:
  • Phone: 941-926-6553
  • Fax: 941-296-8501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9118706
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: