1013424555 NPI number — SHELLEY NICHOLLS APRN

Table of content: SHELLEY NICHOLLS APRN (NPI 1013424555)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013424555 NPI number — SHELLEY NICHOLLS APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NICHOLLS
Provider First Name:
SHELLEY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APRN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HUGHES
Provider Other First Name:
SHELLEY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1013424555
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/30/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1450 NW 10TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIAMI
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33136-1011
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-243-3498
Provider Business Mailing Address Fax Number:
305-243-5791

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1450 NW 10TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIAMI
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33136-1011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-243-3498
Provider Business Practice Location Address Fax Number:
305-243-5791
Provider Enumeration Date:
01/05/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0200X , with the licence number:  9267307 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0200X , with the licence number: APRN9267307 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)