Healthcare Provider Details

I. General information

NPI: 1467752089
Provider Name (Legal Business Name): NICHOLAS PATRICK REEDER CRNA, FNP, IPM, FARM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/29/2010
Last Update Date: 01/26/2024
Certification Date: 07/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 BOATNER RD STE 114
EGLIN AFB FL
32542-1302
US

IV. Provider business mailing address

246 COBB AVE E
CESTVIEW FL
32539
US

V. Phone/Fax

Practice location:
  • Phone: 850-883-9658
  • Fax:
Mailing address:
  • Phone: 850-598-9939
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9262454
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAC002401
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAC002402
License Number StateMD
# 4
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number9262454
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: