Healthcare Provider Details

I. General information

NPI: 1265043392
Provider Name (Legal Business Name): NICOLE IBANEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2020
Last Update Date: 09/13/2022
Certification Date: 08/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1590 TROPIC PARK DR
SANFORD FL
32773-6323
US

IV. Provider business mailing address

121 N HIGHLAND ST
MOUNT DORA FL
32757-5764
US

V. Phone/Fax

Practice location:
  • Phone: 407-202-2220
  • Fax: 407-369-4307
Mailing address:
  • Phone: 352-720-5194
  • Fax: 407-386-7133

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: