Provider Demographics
NPI:1306452768
Name:REDA, NICOLE ASHLEY
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:ASHLEY
Last Name:REDA
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 1:3107 13TH ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34769-5925
Mailing Address - Country:US
Mailing Address - Phone:407-957-7700
Mailing Address - Fax:
Practice Address - Street 1:275 ROUTE 30 N
Practice Address - Street 2:
Practice Address - City:BOMOSEEN
Practice Address - State:VT
Practice Address - Zip Code:05732-9647
Practice Address - Country:US
Practice Address - Phone:802-468-5641
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-21
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11005704363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily