Provider Demographics
NPI:1033296215
Name:NICHOLSON, TANSYLA KEELS (MD)
Entity Type:Individual
Prefix:
First Name:TANSYLA
Middle Name:KEELS
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TANSYLA
Other - Middle Name:DONORA
Other - Last Name:KEELS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:10140 CENTURION PKWY N
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-0532
Mailing Address - Country:US
Mailing Address - Phone:904-697-4127
Mailing Address - Fax:904-697-5102
Practice Address - Street 1:651 N ALAFAYA TRL
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32828-7045
Practice Address - Country:US
Practice Address - Phone:407-273-4132
Practice Address - Fax:407-273-4725
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME101521208000000X
CAA83966208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009347000Medicaid