Healthcare Provider Details

I. General information

NPI: 1467177626
Provider Name (Legal Business Name): RADIAH DAVINA ADAR NIXON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2022
Last Update Date: 03/10/2023
Certification Date: 03/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1130 HICKORY ST STE B
MELBOURNE FL
32901-1973
US

IV. Provider business mailing address

600 LARCH CIR NE
PALM BAY FL
32905-6300
US

V. Phone/Fax

Practice location:
  • Phone: 321-434-7676
  • Fax: 321-952-6179
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11022325
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN11022325
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: