Healthcare Provider Details

I. General information

NPI: 1861203317
Provider Name (Legal Business Name): NICHOLAS ACKRON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2025
Last Update Date: 01/15/2025
Certification Date: 01/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 PRINCE WALTER LN
PALM COAST FL
32164-7151
US

IV. Provider business mailing address

17 PRINCE WALTER LN
PALM COAST FL
32164-7151
US

V. Phone/Fax

Practice location:
  • Phone: 772-494-8337
  • Fax:
Mailing address:
  • Phone: 772-494-8337
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: