1275021768 NPI number — KAITLIN ELAINE NICHOLSON ATC

Table of content: KAITLIN ELAINE NICHOLSON ATC (NPI 1275021768)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275021768 NPI number — KAITLIN ELAINE NICHOLSON ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NICHOLSON
Provider First Name:
KAITLIN
Provider Middle Name:
ELAINE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ATC
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:
KAITLIN
Provider Other Middle Name:
ELAINE
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:
1275021768
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/30/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5598 SUNRISE DR APT 208
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT MYERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33919-1716
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-651-6262
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5598 SUNRISE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT MYERS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33919-1716
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-274-6749
Provider Business Practice Location Address Fax Number:
239-274-6787
Provider Enumeration Date:
04/30/2018

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: 2255A2300X , with the licence number:  AL5015 , 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)

  • Identifier: AL5015 . This is a "FLORIDA DEPARTMENT OF HEALTH AT LICENSURE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".