Healthcare Provider Details

I. General information

NPI: 1023360013
Provider Name (Legal Business Name): MIKE LYNN NICKLESS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2012
Last Update Date: 01/05/2023
Certification Date: 08/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5115 US HIGHWAY 27 N STE 100
SEBRING FL
33870-1323
US

IV. Provider business mailing address

5115 US HIGHWAY 27 N STE 100
SEBRING FL
33870-1323
US

V. Phone/Fax

Practice location:
  • Phone: 863-385-2222
  • Fax: 863-382-8765
Mailing address:
  • Phone: 863-385-2222
  • Fax: 863-382-8765

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberARNP 1259332
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: