Provider Demographics
NPI:1497334171
Name:JIMENEZ, NICOLE (MD)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:
Last Name:JIMENEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 RILEY RD
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34747-5419
Mailing Address - Country:US
Mailing Address - Phone:407-635-3022
Mailing Address - Fax:321-230-4669
Practice Address - Street 1:65 RILEY RD
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34747-5419
Practice Address - Country:US
Practice Address - Phone:407-635-3022
Practice Address - Fax:321-230-4669
Is Sole Proprietor?:No
Enumeration Date:2021-04-07
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME165440207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL120414400Medicaid