=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275408726
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICOLE RODOV
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/06/2025
-----------------------------------------------------
Last Update Date | 10/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12276 SAN JOSE BLVD STE 508
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32223-8618
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-886-3228
-----------------------------------------------------
Fax | 904-485-8876
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 85542 FALL RIVER PKWY
-----------------------------------------------------
City | FERNANDINA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32034-0312
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-557-8026
-----------------------------------------------------
Fax | 904-557-8026
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 13019
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------