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General NPI Number Information
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NPI Number | 1760172761
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Entity Type | Individual
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Provider Name | NICOLE PAULINE DETRICK
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Gender | Female
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Dates
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Enumeration Date | 05/11/2023
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Last Update Date | 12/18/2024
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Provider Practice Location Address
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Address Line | 6269 BEACH BLVD
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City | JACKSONVILLE
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State | FL
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Zip | 32216-2768
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Country | US
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Telephone | 904-727-7955
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Fax |
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Provider Business Mailing Address
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Address Line | 4513 COBBLEFIELD CIR E
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City | JACKSONVILLE
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State | FL
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Zip | 32224-7995
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Country | US
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Telephone | 908-303-4211
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | MA064732
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License Number State | PA
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA9119031
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License Number State | FL
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