Healthcare Provider Details

I. General information

NPI: 1114355708
Provider Name (Legal Business Name): SHARON NICKELL-OLM M D FAMILY MEDICAL CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2013
Last Update Date: 05/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 PREVATT ST
EUSTIS FL
32726-6149
US

IV. Provider business mailing address

2000 PREVATT ST
EUSTIS FL
32726-6149
US

V. Phone/Fax

Practice location:
  • Phone: 352-357-2600
  • Fax: 352-357-3400
Mailing address:
  • Phone: 352-357-2600
  • Fax: 352-357-3400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: SHARON ANN NICKELL-OLM
Title or Position: MD
Credential: MD
Phone: 352-357-2600