Healthcare Provider Details

I. General information

NPI: 1508209214
Provider Name (Legal Business Name): KEVIN NICHOLSON LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2013
Last Update Date: 04/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1674 PLEASANT HILL RD
KISSIMMEE FL
34746-3954
US

IV. Provider business mailing address

PO BOX 407
LOUGHMAN FL
33858-0407
US

V. Phone/Fax

Practice location:
  • Phone: 407-545-9191
  • Fax: 407-641-8918
Mailing address:
  • Phone: 407-545-9191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME101521
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberME101521
License Number StateFL

VIII. Authorized Official

Name: DR. TANSYLA NICHOLSON
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 407-545-9191