Provider Demographics
NPI:1053297754
Name:ROBERTS, NICOLE (NP)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7308 S TRASK ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33616-2123
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3919 TAMPA RD
Practice Address - Street 2:
Practice Address - City:OLDSMAR
Practice Address - State:FL
Practice Address - Zip Code:34677-3114
Practice Address - Country:US
Practice Address - Phone:813-279-1352
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-15
Last Update Date:2025-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11040873363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health