Healthcare Provider Details

I. General information

NPI: 1760703995
Provider Name (Legal Business Name): NICOLE NICOPHENE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2010
Last Update Date: 10/16/2023
Certification Date: 10/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 N PINE ISLAND RD STE 200
PLANTATION FL
33324-1849
US

IV. Provider business mailing address

4780 SW 64TH AVE STE 103
DAVIE FL
33314-4400
US

V. Phone/Fax

Practice location:
  • Phone: 954-424-4321
  • Fax: 954-959-8055
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME-113823
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: