Provider Demographics
NPI:1275021768
Name:NICHOLSON, KAITLIN ELAINE (ATC)
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:ELAINE
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:KAITLIN
Other - Middle Name:ELAINE
Other - Last Name:HUGHES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5598 SUNRISE DR APT 208
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-1716
Mailing Address - Country:US
Mailing Address - Phone:757-651-6262
Mailing Address - Fax:
Practice Address - Street 1:5598 SUNRISE DR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-1716
Practice Address - Country:US
Practice Address - Phone:239-274-6749
Practice Address - Fax:239-274-6787
Is Sole Proprietor?:No
Enumeration Date:2018-04-30
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL50152255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAL5015OtherFLORIDA DEPARTMENT OF HEALTH AT LICENSURE