Healthcare Provider Details

I. General information

NPI: 1508732132
Provider Name (Legal Business Name): NICOLE MARIE NEGRON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2025
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1567 KINGSLEY AVE
ORANGE PARK FL
32073-4510
US

IV. Provider business mailing address

300 INTERNATIONAL PKWY STE 100
LAKE MARY FL
32746-5000
US

V. Phone/Fax

Practice location:
  • Phone: 904-602-9740
  • Fax:
Mailing address:
  • Phone: 706-313-2311
  • Fax: 706-313-2311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: