Provider Demographics
NPI:1043681117
Name:O'CONNOR, NICOLE (AGPCNP)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:O'CONNOR
Suffix:
Gender:F
Credentials:AGPCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10113 COUNT FLEET DR
Mailing Address - Street 2:
Mailing Address - City:RUSKIN
Mailing Address - State:FL
Mailing Address - Zip Code:33573-6772
Mailing Address - Country:US
Mailing Address - Phone:813-362-9588
Mailing Address - Fax:
Practice Address - Street 1:10113 COUNT FLEET DR
Practice Address - Street 2:
Practice Address - City:RUSKIN
Practice Address - State:FL
Practice Address - Zip Code:33573-6772
Practice Address - Country:US
Practice Address - Phone:813-362-9588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-14
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAG1015006363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner