MEDICARE: NICOLE A DEVLIEGER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	AL4899	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	7272650995	OTHER		PHONE

General Provider Information

NPI Number	:	1033654843
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE A DEVLIEGER

Provider Business Mailing Address
First Line	:	11526 LEDA LN
Second Line	:
City	:	NEW PORT RICHEY
State	:	FL
Zip	:	34654-6237
Country	:	US
Telephone Number	:	727-265-0995
Fax Number	:

Provider Business Practice Location Address
First Line	:	4539 S DALE MABRY HWY STE 110
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33611
Country	:	US
Telephone Number	:	813-250-1208
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/03/2017
Last Update Date	:	08/01/2019

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Directions to “ NICOLE A DEVLIEGER ” Practice Location

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