Provider Demographics
NPI:1497743637
Name:THREADGILL, NICHELLE L (MD)
Entity Type:Individual
Prefix:
First Name:NICHELLE
Middle Name:L
Last Name:THREADGILL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NICHELLE
Other - Middle Name:
Other - Last Name:JEAN-BAPTISTE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1344 22ND ST S
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33712-2744
Mailing Address - Country:US
Mailing Address - Phone:727-821-6701
Mailing Address - Fax:727-823-7429
Practice Address - Street 1:1344 22ND ST S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33712-2744
Practice Address - Country:US
Practice Address - Phone:727-821-6701
Practice Address - Fax:727-823-7429
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME81010208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL260234200Medicaid