Provider Demographics
NPI:1508648635
Name:NICHOLSON, KATIE (APRN)
Entity Type:Individual
Prefix:MRS
First Name:KATIE
Middle Name:
Last Name:NICHOLSON
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 1:7116 TWELVE OAKS DR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-5671
Mailing Address - Country:US
Mailing Address - Phone:863-221-8215
Mailing Address - Fax:
Practice Address - Street 1:5950 S FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-2532
Practice Address - Country:US
Practice Address - Phone:863-688-3550
Practice Address - Fax:863-687-8969
Is Sole Proprietor?:No
Enumeration Date:2023-10-13
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11027976363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily