Healthcare Provider Details

I. General information

NPI: 1003160896
Provider Name (Legal Business Name): NICOLE ALYSON MCCLONE DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2012
Last Update Date: 10/09/2023
Certification Date: 10/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3055 COUNTY ROAD 210 W STE 110
ST JOHNS FL
32259
US

IV. Provider business mailing address

6800 SOUTHPOINT PKWY STE 300
JACKSONVILLE FL
32216-8203
US

V. Phone/Fax

Practice location:
  • Phone: 904-825-0540
  • Fax: 904-825-2490
Mailing address:
  • Phone: 904-634-0640
  • Fax: 46-340-2039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberPT27401
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT27401
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: