Provider Demographics
NPI:1568619476
Name:OUTTEN, NICOLE (MD)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:OUTTEN
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 1:2776 CLEVELAND AVE
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-5864
Mailing Address - Country:US
Mailing Address - Phone:239-343-2606
Mailing Address - Fax:
Practice Address - Street 1:2776 CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901
Practice Address - Country:US
Practice Address - Phone:239-343-2606
Practice Address - Fax:239-343-3695
Is Sole Proprietor?:No
Enumeration Date:2008-08-21
Last Update Date:2025-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104426363A00000X
FL43349390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001888400Medicaid