1528133097 NPI number — NICOLE-ANN MARIA PRESTWIDGE PA-C

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 1528133097 NPI number — NICOLE-ANN MARIA PRESTWIDGE PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PRESTWIDGE
Provider First Name:
NICOLE-ANN
Provider Middle Name:
MARIA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1528133097
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15490 SW 134TH PL
Provider Second Line Business Mailing Address:
APT 502
Provider Business Mailing Address City Name:
MIAMI
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33177-8122
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-971-4354
Provider Business Mailing Address Fax Number:
305-971-4654

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11373 SW 211TH ST
Provider Second Line Business Practice Location Address:
SUITE 16
Provider Business Practice Location Address City Name:
MIAMI
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33189-2245
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-234-0009
Provider Business Practice Location Address Fax Number:
305-234-8688
Provider Enumeration Date:
11/21/2006

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: 363A00000X , with the licence number:  PA 9103079 , 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)





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