Provider Demographics
NPI:1629097555
Name:NICHOLAS, MOLLY ANNE (ARNP)
Entity Type:Individual
Prefix:MS
First Name:MOLLY
Middle Name:ANNE
Last Name:NICHOLAS
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:NICHOLAS
Other - Last Name:KNISLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:8117 SW 12TH PL
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32607-3329
Mailing Address - Country:US
Mailing Address - Phone:352-317-6361
Mailing Address - Fax:
Practice Address - Street 1:5818 CENTRE ST
Practice Address - Street 2:
Practice Address - City:MELROSE
Practice Address - State:FL
Practice Address - Zip Code:32666-6207
Practice Address - Country:US
Practice Address - Phone:352-475-3792
Practice Address - Fax:352-475-3794
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3048822363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
11711668OtherCAQH
FL306300300Medicaid
11711668OtherCAQH
FLAA147WMedicare PIN