Provider Demographics
NPI:1417496266
Name:NICKS, RAEDYANCE
Entity Type:Individual
Prefix:
First Name:RAEDYANCE
Middle Name:
Last Name:NICKS
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 1:3303 N LAKEVIEW DR
Mailing Address - Street 2:APT 3103
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33618-1364
Mailing Address - Country:US
Mailing Address - Phone:340-277-4141
Mailing Address - Fax:
Practice Address - Street 1:27604 CASHFORD CIR
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33544-6952
Practice Address - Country:US
Practice Address - Phone:813-345-8584
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-13
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician