Healthcare Provider Details

I. General information

NPI: 1164858882
Provider Name (Legal Business Name): NICOLE SCOTT PA, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2013
Last Update Date: 10/28/2022
Certification Date: 10/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8931 COLONIAL CENTER DR STE 300
FORT MYERS FL
33905-7809
US

IV. Provider business mailing address

PO BOX 102222
ATLANTA GA
30368-2222
US

V. Phone/Fax

Practice location:
  • Phone: 239-938-0800
  • Fax: 239-938-0890
Mailing address:
  • Phone: 239-274-8200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAL4456
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number021612
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9107524
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: