Healthcare Provider Details

I. General information

NPI: 1437780764
Provider Name (Legal Business Name): CHANTAL MARIE NICHOLS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2020
Last Update Date: 02/19/2020
Certification Date: 02/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 N MAIN ST
WILLISTON FL
32696-1705
US

IV. Provider business mailing address

23343 NW COUNTY ROAD 236
HIGH SPRINGS FL
32643-9669
US

V. Phone/Fax

Practice location:
  • Phone: 352-528-0587
  • Fax: 352-528-4834
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberAPRN11005897
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11005897
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: