Healthcare Provider Details

I. General information

NPI: 1780366740
Provider Name (Legal Business Name): NICOLE LEACH APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2023
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1208 E WADE ST STE L
TRENTON FL
32693-2780
US

IV. Provider business mailing address

9910 S SANTA FE AVE
TRENTON FL
32693-2624
US

V. Phone/Fax

Practice location:
  • Phone: 352-318-3563
  • Fax: 352-741-5750
Mailing address:
  • Phone: 352-215-1091
  • Fax: 352-741-5750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11028993
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN9341468
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: