Provider Demographics
NPI:1679669808
Name:LAKE MARY OB/GYN
Entity Type:Organization
Organization Name:LAKE MARY OB/GYN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DO
Authorized Official - Prefix:
Authorized Official - First Name:ERIKA
Authorized Official - Middle Name:
Authorized Official - Last Name:NICHELSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:407-323-2727
Mailing Address - Street 1:2500 W LAKE MARY BLVD
Mailing Address - Street 2:SUITE 109
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-3501
Mailing Address - Country:US
Mailing Address - Phone:407-323-2727
Mailing Address - Fax:407-323-2771
Practice Address - Street 1:2500 W LAKE MARY BLVD
Practice Address - Street 2:SUITE 109
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-3501
Practice Address - Country:US
Practice Address - Phone:407-323-2727
Practice Address - Fax:407-323-2771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty