Healthcare Provider Details

I. General information

NPI: 1063234227
Provider Name (Legal Business Name): MICHELE RENEE NICHOLS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2024
Last Update Date: 10/29/2024
Certification Date: 10/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

247 SW PORT ST LUCIE BLVD
PORT SAINT LUCIE FL
34984
US

IV. Provider business mailing address

7500 SAN FELIPE ST. SUITE 990
HOUSTON TX
77063
US

V. Phone/Fax

Practice location:
  • Phone: 772-207-1356
  • Fax: 772-742-2924
Mailing address:
  • Phone: 866-610-0580
  • Fax: 866-611-1558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: