Provider Demographics
NPI:1215432224
Name:BACON, NICKOLE AIMEE (APRN-C)
Entity type:Individual
Prefix:MRS
First Name:NICKOLE
Middle Name:AIMEE
Last Name:BACON
Suffix:
Gender:F
Credentials:APRN-C
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:2995 DREW ST FL 2
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33759-3012
Mailing Address - Country:US
Mailing Address - Phone:727-532-1355
Mailing Address - Fax:813-635-2613
Practice Address - Street 1:3301 W GANDY BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33611-2931
Practice Address - Country:US
Practice Address - Phone:813-925-1903
Practice Address - Fax:813-749-8370
Is Sole Proprietor?:No
Enumeration Date:2018-03-30
Last Update Date:2025-05-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLAPRN9365609363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL024515800Medicaid