MEDICARE: NICOLE NISS

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	2255A2300X	Athletic Trainer	AL 3841	FL

General Provider Information

NPI Number	:	1205244811
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE NISS

Provider Business Mailing Address
First Line	:	309 AMARYLISS WAY
Second Line	:
City	:	OVIEDO
State	:	FL
Zip	:	32765-9312
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4180 N ORION BLVD BLDG 77
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32816-8029
Country	:	US
Telephone Number	:	407-823-0031
Fax Number	:

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

Provider Enumeration Date	:	07/27/2014
Last Update Date	:	07/27/2014

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Directions to “ NICOLE NISS ” Practice Location

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