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General NPI Number Information
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NPI Number | 1205244811
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Entity Type | Individual
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Provider Name | NICOLE NISS
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Gender | Female
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Dates
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Enumeration Date | 07/27/2014
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Last Update Date | 07/27/2014
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Provider Practice Location Address
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Address Line | 4180 N ORION BLVD BLDG 77
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City | ORLANDO
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State | FL
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Zip | 32816-8029
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Country | US
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Telephone | 407-823-0031
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Fax |
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Provider Business Mailing Address
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Address Line | 309 AMARYLISS WAY
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City | OVIEDO
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State | FL
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Zip | 32765-9312
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | AL 3841
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License Number State | FL
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