Provider Demographics
NPI:1285358291
Name:CROSSLEY, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:CROSSLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2090 S HIGHWAY 29
Mailing Address - Street 2:
Mailing Address - City:CANTONMENT
Mailing Address - State:FL
Mailing Address - Zip Code:32533-8699
Mailing Address - Country:US
Mailing Address - Phone:850-501-3260
Mailing Address - Fax:
Practice Address - Street 1:2090 S HIGHWAY 29
Practice Address - Street 2:
Practice Address - City:CANTONMENT
Practice Address - State:FL
Practice Address - Zip Code:32533-8699
Practice Address - Country:US
Practice Address - Phone:850-501-3260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-03
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS53526183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPH20939OtherLICENSE NUMBER