Healthcare Provider Details

I. General information

NPI: 1679222053
Provider Name (Legal Business Name): NICOLE LYNN VENTURINI FLORA LMBT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2022
Last Update Date: 12/16/2024
Certification Date: 12/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

138 MINE LAKE CT STE 200
RALEIGH NC
27615-6417
US

IV. Provider business mailing address

138 MINE LAKE CT STE 200
RALEIGH NC
27615-6417
US

V. Phone/Fax

Practice location:
  • Phone: 919-825-7115
  • Fax:
Mailing address:
  • Phone: 919-825-7115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number12456
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number12456
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: