Healthcare Provider Details

I. General information

NPI: 1467315242
Provider Name (Legal Business Name): AUDREY JANE NOLES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2025
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13127 VAIL RIDGE DR
RIVERVIEW FL
33579-7196
US

IV. Provider business mailing address

4310 BURLINGTON AVE N
SAINT PETERSBURG FL
33713-7326
US

V. Phone/Fax

Practice location:
  • Phone: 813-661-6199
  • Fax: 813-661-6334
Mailing address:
  • Phone: 734-341-5317
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11044094
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: