Healthcare Provider Details

I. General information

NPI: 1659056950
Provider Name (Legal Business Name): NYCOLLE AUTIMN LFE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2023
Last Update Date: 06/15/2023
Certification Date: 06/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5768 S SEMORAN BLVD
ORLANDO FL
32822-4818
US

IV. Provider business mailing address

2005 PONDEROSA AVE
WINTER PARK FL
32792-2063
US

V. Phone/Fax

Practice location:
  • Phone: 407-896-2323
  • Fax:
Mailing address:
  • Phone: 407-457-4471
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: