MEDICARE: NICOLE LAND DO

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	207P00000X	Emergency Medicine Physician	OS18935	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1649733957
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE LAND DO

Provider Business Mailing Address
First Line	:	7 STAYMAN LN
Second Line	:
City	:	SEWELL
State	:	NJ
Zip	:	08080-3030
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2534 PGA BLVD
Second Line	:
City	:	PALM BEACH GARDENS
State	:	FL
Zip	:	33410-2902
Country	:	US
Telephone Number	:	561-295-8822
Fax Number	:	215-955-9870

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

Provider Enumeration Date	:	04/12/2019
Last Update Date	:	08/01/2022

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Directions to “ NICOLE LAND DO” Practice Location

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