Provider Demographics
NPI:1639498991
Name:LAVELLE, NICHOLAS JOHN (LMT)
Entity Type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:JOHN
Last Name:LAVELLE
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 W FRIBLEY ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33603-5413
Mailing Address - Country:US
Mailing Address - Phone:813-294-5800
Mailing Address - Fax:
Practice Address - Street 1:801 W FRIBLEY ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33603-5413
Practice Address - Country:US
Practice Address - Phone:813-294-5800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-26
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA31275174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist