Provider Demographics
NPI:1427289016
Name:NICOLETTO, DIEDRA MICHELLE (MA39156)
Entity type:Individual
Prefix:
First Name:DIEDRA
Middle Name:MICHELLE
Last Name:NICOLETTO
Suffix:
Gender:F
Credentials:MA39156
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4851
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33758-4851
Mailing Address - Country:US
Mailing Address - Phone:727-313-2882
Mailing Address - Fax:727-313-9566
Practice Address - Street 1:801 TURNER ST
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33756-5633
Practice Address - Country:US
Practice Address - Phone:727-313-2882
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-31
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA39156225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist