Provider Demographics
NPI:1598217747
Name:NICKERSON, ASTORIA
Entity Type:Individual
Prefix:
First Name:ASTORIA
Middle Name:
Last Name:NICKERSON
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:PO BOX 703
Mailing Address - Street 2:
Mailing Address - City:KEY WEST
Mailing Address - State:FL
Mailing Address - Zip Code:33041-0703
Mailing Address - Country:US
Mailing Address - Phone:321-888-4564
Mailing Address - Fax:
Practice Address - Street 1:1612 TRUESDELL CT
Practice Address - Street 2:
Practice Address - City:KEY WEST
Practice Address - State:FL
Practice Address - Zip Code:33040-0703
Practice Address - Country:US
Practice Address - Phone:321-888-4564
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-03
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator