1861404899 NPI number — NICOLE ELAINE FIFER PAC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861404899 NPI number — NICOLE ELAINE FIFER PAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FIFER
Provider First Name:
NICOLE
Provider Middle Name:
ELAINE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PAC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SCHARRER
Provider Other First Name:
NICOLE
Provider Other Middle Name:
ELAINE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1861404899
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/31/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 45443
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84145-0443
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-202-1032
Provider Business Mailing Address Fax Number:
904-376-4107

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1400 BISHOP ESTATES RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32259-4244
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-287-2794
Provider Business Practice Location Address Fax Number:
904-287-5362
Provider Enumeration Date:
08/11/2006

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: 363AM0700X , with the licence number:  PA200082 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: PA200082 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: PA9108411 , 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: 1013510 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 017157500 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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