Provider Demographics
NPI:1558312025
Name:TYRRELL, NICOLE ANNE (OD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:ANNE
Last Name:TYRRELL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4101 EVANS AVE
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901
Mailing Address - Country:US
Mailing Address - Phone:239-335-1944
Mailing Address - Fax:239-939-1575
Practice Address - Street 1:4101 EVANS AVE
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901
Practice Address - Country:US
Practice Address - Phone:239-939-3456
Practice Address - Fax:239-936-8776
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3522152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL620553400Medicaid
FL8780436OtherCIGNA
FL20937OtherBLUE CROSS BLUE SHIELD
FL620553400Medicaid
FL20937ZMedicare ID - Type Unspecified