=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649691122
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL SCOTT NICKERSON MS, ARNP-C, COHN-S
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/30/2013
-----------------------------------------------------
Last Update Date | 01/07/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 700 5TH AVE S
-----------------------------------------------------
City | ST. PETERSBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33785
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-767-8404
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2625 NE 14TH AVE APT 105
-----------------------------------------------------
City | OAKLAND PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33334-4395
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-777-9788
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | 3297762
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------