MEDICARE: NICOLE A WEISS

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	174400000X	Specialist

General Provider Information

NPI Number	:	1346352853
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE A WEISS

Provider Business Mailing Address
First Line	:	7137 TARPON CT
Second Line	:
City	:	GREEN COVE SPRINGS
State	:	FL
Zip	:	32043-3785
Country	:	US
Telephone Number	:	904-891-0144
Fax Number	:

Provider Business Practice Location Address
First Line	:	7137 TARPON CT
Second Line	:
City	:	GREEN COVE SPRINGS
State	:	FL
Zip	:	32043-3785
Country	:	US
Telephone Number	:	904-891-0144
Fax Number	:

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

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	07/08/2007

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Directions to “ NICOLE A WEISS ” Practice Location

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