Provider Demographics
NPI:1942193008
Name:SMITH, NICHELLE RENEE
Entity type:Individual
Prefix:
First Name:NICHELLE
Middle Name:RENEE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4733 FIRESIDE CT
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210-9307
Mailing Address - Country:US
Mailing Address - Phone:904-651-6432
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 2543
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32203-2543
Practice Address - Country:US
Practice Address - Phone:904-651-6432
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-29
Last Update Date:2025-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL240694376J00000X, 372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion
No376J00000XNursing Service Related ProvidersHomemaker