Healthcare Provider Details

I. General information

NPI: 1851885180
Provider Name (Legal Business Name): NIKKI SYTSMA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2018
Last Update Date: 06/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1210 S LAMAR ST APT 1349
DALLAS TX
75215-1053
US

IV. Provider business mailing address

1210 S LAMAR ST APT 1349
DALLAS TX
75215-1053
US

V. Phone/Fax

Practice location:
  • Phone: 239-823-1066
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberPN5225650
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: