Provider Demographics
NPI:1023360013
Name:NICKLESS, MIKE LYNN (CRNA)
Entity Type:Individual
Prefix:MR
First Name:MIKE
Middle Name:LYNN
Last Name:NICKLESS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5115 US HIGHWAY 27 N STE 100
Mailing Address - Street 2:
Mailing Address - City:SEBRING
Mailing Address - State:FL
Mailing Address - Zip Code:33870-1323
Mailing Address - Country:US
Mailing Address - Phone:863-385-2222
Mailing Address - Fax:863-382-8765
Practice Address - Street 1:5115 US HIGHWAY 27 N STE 100
Practice Address - Street 2:
Practice Address - City:SEBRING
Practice Address - State:FL
Practice Address - Zip Code:33870-1323
Practice Address - Country:US
Practice Address - Phone:863-385-2222
Practice Address - Fax:863-382-8765
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-15
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 1259332367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered