Provider Demographics
NPI:1134637630
Name:TWITTY, NICHOLAS RAY
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:RAY
Last Name:TWITTY
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 1:2123 ROYAL POINCIANA BLVD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-3396
Mailing Address - Country:US
Mailing Address - Phone:850-226-3820
Mailing Address - Fax:
Practice Address - Street 1:2123 ROYAL POINCIANA BLVD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-3396
Practice Address - Country:US
Practice Address - Phone:850-226-3820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-18
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA28186225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant