Basic Information
| Provider Information | |||||||||
| NPI: | 1912467598 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LOUIS | ||||||||
| FirstName: | NICOLE | ||||||||
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| Credential: | PHYSICIAN ASSISTANT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3375 BURNS RD | ||||||||
| Address2: | SUITE 206 | ||||||||
| City: | PALM BEACH GARDEN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334104349 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617999559 | ||||||||
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| Practice Location | |||||||||
| Address1: | 901 45TH ST | ||||||||
| Address2: | |||||||||
| City: | MANGONIA PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334072413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5618446300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2019 | ||||||||
| LastUpdateDate: | 10/26/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 9112025 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.