Provider Demographics
NPI:1679697882
Name:GAYLE-NICHOLSON, JACQUELINE (CNM)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:GAYLE-NICHOLSON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:GAYLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM
Mailing Address - Street 1:2800 S SEACREST BLVD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33435-7960
Mailing Address - Country:US
Mailing Address - Phone:561-742-3929
Mailing Address - Fax:561-742-3931
Practice Address - Street 1:2800 S SEACREST BLVD
Practice Address - Street 2:SUITE 220
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33435-7960
Practice Address - Country:US
Practice Address - Phone:561-742-3929
Practice Address - Fax:561-742-3931
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2017-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2514592367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL300715400Medicaid
FLY0881OtherBCBS