MEDICARE: NICOLE HUDSON OTR/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	OT17301	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	68-6520	OTHER	FL	MEDICARE GROUP

General Provider Information

NPI Number	:	1124497177
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE HUDSON OTR/L

Provider Business Mailing Address
First Line	:	2328 HANCOCK BRIDGE PKWY
Second Line	:	SUITE 103
City	:	CAPE CORAL
State	:	FL
Zip	:	33990-1459
Country	:	US
Telephone Number	:	239-573-1518
Fax Number	:	239-573-7356

Provider Business Practice Location Address
First Line	:	2328 HANCOCK BRIDGE PKWY STE 103
Second Line	:
City	:	CAPE CORAL
State	:	FL
Zip	:	33990-1455
Country	:	US
Telephone Number	:	239-574-7557
Fax Number	:	239-574-1315

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/21/2015
Last Update Date	:	01/18/2016

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