1013469279 NPI number — NIKOLE RAE ORTA ARNP

Table of content: NIKOLE RAE ORTA ARNP (NPI 1013469279)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013469279 NPI number — NIKOLE RAE ORTA ARNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ORTA
Provider First Name:
NIKOLE
Provider Middle Name:
RAE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ARNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BROOM-SMITH
Provider Other First Name:
NIKOLE
Provider Other Middle Name:
RAE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
ARNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1013469279
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/04/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 25317
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TAMPA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33622-5317
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-286-0033
Provider Business Mailing Address Fax Number:
813-282-0806

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1344 22ND ST S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST PETERSBURG
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33712-2744
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-824-8181
Provider Business Practice Location Address Fax Number:
727-824-8137
Provider Enumeration Date:
11/03/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  9327079 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 019680100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".