Basic Information
| Provider Information | |||||||||
| NPI: | 1659680007 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MASSE | ||||||||
| FirstName: | NICOLA | ||||||||
| MiddleName: | ANNE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5310 NW 33RD AVE | ||||||||
| Address2: | SUITE 216 | ||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333096376 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9547319676 | ||||||||
| FaxNumber: | 9547319747 | ||||||||
| Practice Location | |||||||||
| Address1: | 12957 PALMS WEST DR | ||||||||
| Address2: | BLDG. 9, SUITE 202 | ||||||||
| City: | LOXAHATCHEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334704932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617955979 | ||||||||
| FaxNumber: | 5617959460 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2010 | ||||||||
| LastUpdateDate: | 10/04/2010 | ||||||||
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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 | ME83290 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 263118100 | 05 | FL | MEDICAID |