Healthcare Provider Details

I. General information

NPI: 1104514132
Provider Name (Legal Business Name): NICOLE BRYAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2023
Last Update Date: 04/28/2023
Certification Date: 04/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4519 WOODBINE RD
PACE FL
32571-8706
US

IV. Provider business mailing address

4725 WINTERDALE DR
PACE FL
32571-1371
US

V. Phone/Fax

Practice location:
  • Phone: 850-778-3747
  • Fax:
Mailing address:
  • Phone: 850-529-8852
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH22118
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: