Basic Information
| Provider Information | |||||||||
| NPI: | 1104821644 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CRAVEN | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1201 LOUISIANA AVE | ||||||||
| Address2: | SUITE E | ||||||||
| City: | WINTER PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327892340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076442990 | ||||||||
| FaxNumber: | 4076444370 | ||||||||
| Practice Location | |||||||||
| Address1: | 1201 LOUISIANA AVE | ||||||||
| Address2: | SUITE E | ||||||||
| City: | WINTER PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327892340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076442990 | ||||||||
| FaxNumber: | 4076444370 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2005 | ||||||||
| LastUpdateDate: | 10/10/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 2004-01378 | NC | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 13837 | 01 | NC | BLUE CROSS PROVIDER # | OTHER | 2468828 | 01 | NC | UNITED HEALTHCARE | OTHER | 5908891 | 05 | NC | MEDICAID | 7280705 | 01 | NC | AETNA | OTHER |