Provider Demographics
NPI:1073249173
Name:NICHOLLS, DANIEL JAMES
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:JAMES
Last Name:NICHOLLS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:842 S LILAC LOOP
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-1919
Mailing Address - Country:US
Mailing Address - Phone:727-348-8080
Mailing Address - Fax:
Practice Address - Street 1:842 S LILAC LOOP
Practice Address - Street 2:
Practice Address - City:SAINT JOHNS
Practice Address - State:FL
Practice Address - Zip Code:32259-1919
Practice Address - Country:US
Practice Address - Phone:727-348-8080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-29
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program