Provider Demographics
NPI:1407555469
Name:MATIAS-BADO, NICOLE LORRAINE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:LORRAINE
Last Name:MATIAS-BADO
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 6TH ST S
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-4814
Mailing Address - Country:US
Mailing Address - Phone:939-242-9172
Mailing Address - Fax:
Practice Address - Street 1:701 6TH ST S
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4814
Practice Address - Country:US
Practice Address - Phone:727-823-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-28
Last Update Date:2025-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001307440163W00000X
FL11037409367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse