Provider Demographics
NPI:1629127188
Name:NICHOLSON, KIMBERLY A (MD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12730 NEW BRITTANY BLVD STE 602
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-4690
Mailing Address - Country:US
Mailing Address - Phone:239-275-5522
Mailing Address - Fax:239-275-4464
Practice Address - Street 1:9350 CAMELOT DR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-7980
Practice Address - Country:US
Practice Address - Phone:239-481-5437
Practice Address - Fax:239-481-0571
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME102851208000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL93132OtherBCBS FLORIDA
FL000607900Medicaid
OH2482086Medicaid
FL000607900Medicaid
OHNI7351741Medicare ID - Type Unspecified
FL93132OtherBCBS FLORIDA