MEDICARE: MRS. DONNA SOAVE NICHOLS P.T.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT15569	FL

General Provider Information

NPI Number	:	1710987359
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DONNA SOAVE NICHOLS P.T.

Provider Business Mailing Address
First Line	:	210 SUMMERWOOD DR
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32413-5731
Country	:	US
Telephone Number	:	850-896-3405
Fax Number	:

Provider Business Practice Location Address
First Line	:	7328 THOMAS DR
Second Line	:	SUITE G
City	:	PANAMA CITY
State	:	FL
Zip	:	32408-7500
Country	:	US
Telephone Number	:	850-236-3424
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/26/2005
Last Update Date	:	08/14/2012

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