Provider Demographics
NPI:1154078103
Name:MAXMILLIAN, NIMMI
Entity Type:Individual
Prefix:
First Name:NIMMI
Middle Name:
Last Name:MAXMILLIAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10107 TUSCAN SUN AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33578-9308
Mailing Address - Country:US
Mailing Address - Phone:813-220-3122
Mailing Address - Fax:
Practice Address - Street 1:2020 TOWN CENTER BLVD STE C
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-2906
Practice Address - Country:US
Practice Address - Phone:813-633-1980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-09
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11018577363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty