Provider Demographics
NPI:1285099044
Name:SAUNDERS, NICOLE (MS)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:SAUNDERS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2818 CEDARCREST DR
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-6512
Mailing Address - Country:US
Mailing Address - Phone:724-923-8722
Mailing Address - Fax:904-278-5659
Practice Address - Street 1:2818 CEDARCREST DR
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-6512
Practice Address - Country:US
Practice Address - Phone:724-923-8722
Practice Address - Fax:904-291-5572
Is Sole Proprietor?:No
Enumeration Date:2015-12-22
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
FLMH15669101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMA0239Medicaid