Healthcare Provider Details

I. General information

NPI: 1720665565
Provider Name (Legal Business Name): NICOLE MARIELLA PABON GONZALEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2021
Last Update Date: 08/09/2025
Certification Date: 08/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300 ALTON RD
MIAMI FL
33140-2948
US

IV. Provider business mailing address

4300 ALTON ROAD
MIAMI FL
33140
US

V. Phone/Fax

Practice location:
  • Phone: 305-674-2121
  • Fax:
Mailing address:
  • Phone: 305-674-2121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number36240
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: