Healthcare Provider Details

I. General information

NPI: 1508778481
Provider Name (Legal Business Name): NICOLE LANNAN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2026
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4210 VALLEY RIDGE BLVD STE 110
PONTE VEDRA FL
32081-5171
US

IV. Provider business mailing address

184 TURTLE COVE CT
PONTE VEDRA BEACH FL
32082-4517
US

V. Phone/Fax

Practice location:
  • Phone: 904-747-6403
  • Fax:
Mailing address:
  • Phone: 904-747-6403
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11034259
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: