Healthcare Provider Details

I. General information

NPI: 1063659944
Provider Name (Legal Business Name): CYNTHIA ANN NUCKOLS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/14/2009
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3955 INDIAN RIVER DR
COCOA FL
32926-5941
US

IV. Provider business mailing address

3955 INDIAN RIVER DRIVE SUITE 6
COCOA FL
32926
US

V. Phone/Fax

Practice location:
  • Phone: 321-634-3688
  • Fax: 321-504-0955
Mailing address:
  • Phone: 321-427-3825
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: