Healthcare Provider Details

I. General information

NPI: 1558912105
Provider Name (Legal Business Name): DANIELLE NICHOLSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2019
Last Update Date: 11/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 S FORT HARRISON AVE STE 101
CLEARWATER FL
33756
US

IV. Provider business mailing address

2098 SEMINOLE BLVD APT 6103
LARGO FL
33778-1728
US

V. Phone/Fax

Practice location:
  • Phone: 727-441-5044
  • Fax:
Mailing address:
  • Phone: 954-598-3981
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: