Healthcare Provider Details

I. General information

NPI: 1821655929
Provider Name (Legal Business Name): LAURENZCO NICHOLSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2019
Last Update Date: 11/07/2022
Certification Date: 11/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730 GOODLETTE-FRANK RD N STE 100
NAPLES FL
34102-5617
US

IV. Provider business mailing address

PO BOX 25487
SARASOTA FL
34277-2487
US

V. Phone/Fax

Practice location:
  • Phone: 239-351-2990
  • Fax: 239-300-4128
Mailing address:
  • Phone: 941-202-5342
  • Fax: 855-253-4836

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number15221-I
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME156999
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: