Provider Demographics
NPI:1326566803
Name:NICHOLAS, KACIE (DPT)
Entity Type:Individual
Prefix:
First Name:KACIE
Middle Name:
Last Name:NICHOLAS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:489 WALNUT DR
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-7010
Mailing Address - Country:US
Mailing Address - Phone:304-771-5223
Mailing Address - Fax:
Practice Address - Street 1:1000 W BROADWAY ST STE 214
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-9262
Practice Address - Country:US
Practice Address - Phone:407-359-5693
Practice Address - Fax:407-792-5693
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-05
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL30999225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist