1063722684 NPI number — DR. WILLIS TYLER NICHOLS M.D.

Table of content: MONICA PONCE (NPI 1487817557)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063722684 NPI number — DR. WILLIS TYLER NICHOLS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NICHOLS
Provider First Name:
WILLIS
Provider Middle Name:
TYLER
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

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

NPI Number Information

NPI Number:
1063722684
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/14/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1711 N MCKENZIE ST STE 201
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FOLEY
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36535-2282
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
251-949-3479
Provider Business Mailing Address Fax Number:
251-949-3434

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1711 N MCKENZIE ST STE 201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FOLEY
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36535-2282
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
251-424-1620
Provider Business Practice Location Address Fax Number:
251-952-6620
Provider Enumeration Date:
10/15/2010

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: 208600000X , with the licence number:  34161 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 214769 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 105926100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 211911 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00187592 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 105926100 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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