MEDICARE: NICOLE CAROLYN LAFAILLE

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	172V00000X	Community Health Worker

General Provider Information

NPI Number	:	1710764253
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE CAROLYN LAFAILLE

Provider Business Mailing Address
First Line	:	11820 SAGEBRUSH CT
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32218-3647
Country	:	US
Telephone Number	:	850-533-5626
Fax Number	:

Provider Business Practice Location Address
First Line	:	11820 SAGEBRUSH CT
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32218-3647
Country	:	US
Telephone Number	:	850-533-5626
Fax Number	:

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

Provider Enumeration Date	:	09/08/2023
Last Update Date	:	09/08/2023

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Directions to “ NICOLE CAROLYN LAFAILLE ” Practice Location

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