Provider Demographics
NPI:1255311528
Name:NICHOLS, JUDITH LYNN (APRN)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:LYNN
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3123
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32085-3123
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:105 MARINER WAY
Practice Address - Street 2:STE 203
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086
Practice Address - Country:US
Practice Address - Phone:904-342-2989
Practice Address - Fax:904-824-6243
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN978502363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL303357100Medicaid
FLY0484OtherBCBS
FLP00050120OtherRAILROAD MEDICARE
FLE4323LMedicare PIN
FLP00050120OtherRAILROAD MEDICARE
FL303357100Medicaid