Healthcare Provider Details

I. General information

NPI: 1194065870
Provider Name (Legal Business Name): ISIDORA NICHOLS ATC, LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/18/2013
Last Update Date: 02/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 BARTRAM OAKS WALK STE. 104
SAINT JOHNS FL
32259-3243
US

IV. Provider business mailing address

9765 SOUTHBROOK DR APT. 2203
JACKSONVILLE FL
32256-0459
US

V. Phone/Fax

Practice location:
  • Phone: 904-240-0471
  • Fax: 904-240-0471
Mailing address:
  • Phone: 863-712-0988
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAL 2854
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: