Healthcare Provider Details

I. General information

NPI: 1851842629
Provider Name (Legal Business Name): NANCY TIKUNOFF
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2016
Last Update Date: 10/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

274 STONE ISLAND RD
ENTERPRISE FL
32725-2421
US

IV. Provider business mailing address

274 STONE ISLAND RD
ENTERPRISE FL
32725-2421
US

V. Phone/Fax

Practice location:
  • Phone: 479-236-3803
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH15235
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN9224052
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: