Healthcare Provider Details

I. General information

NPI: 1447182761
Provider Name (Legal Business Name): TYLER JACKSON NICHOLS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2026
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9160 FORUM CORPORATE PKWY STE 350
FORT MYERS FL
33905-7808
US

IV. Provider business mailing address

2274 LEE TER
PORT CHARLOTTE FL
33952-4129
US

V. Phone/Fax

Practice location:
  • Phone: 941-525-4093
  • Fax:
Mailing address:
  • Phone: 941-525-4093
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberAS5980
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: