Basic Information
| Provider Information | |||||||||
| NPI: | 1851542468 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FIELDS | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | MICHELLE | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 S PINE ISLAND RD STE 800 | ||||||||
| Address2: | |||||||||
| City: | PLANTATION | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333243923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052458050 | ||||||||
| FaxNumber: | 3052455950 | ||||||||
| Practice Location | |||||||||
| Address1: | 3084 NE 41ST TER | ||||||||
| Address2: | |||||||||
| City: | HOMESTEAD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052458050 | ||||||||
| FaxNumber: | 3052455950 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2008 | ||||||||
| LastUpdateDate: | 08/31/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | OS11204 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 003591000 | 05 | FL | MEDICAID |