Provider Demographics
NPI:1174063127
Name:POLBOS, NICOLE (ARNP)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:
Last Name:POLBOS
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1283 SW STATE ROAD 47
Mailing Address - Street 2:SUITE 104
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-0489
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1283 SW STATE ROAD 47
Practice Address - Street 2:SUITE 104
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-0489
Practice Address - Country:US
Practice Address - Phone:386-758-5985
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-24
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 9265534363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care