Provider Demographics
NPI:1689880411
Name:NICHOLSON, MARY KATHERINE TEISINGER (AP, DOM)
Entity Type:Individual
Prefix:MRS
First Name:MARY KATHERINE
Middle Name:TEISINGER
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:AP, DOM
Other - Prefix:DR
Other - First Name:KATHERINE
Other - Middle Name:
Other - Last Name:TEISINGER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:AP, DOM
Mailing Address - Street 1:535 E PIERCE ST
Mailing Address - Street 2:
Mailing Address - City:LAKE ALFRED
Mailing Address - State:FL
Mailing Address - Zip Code:33850-3027
Mailing Address - Country:US
Mailing Address - Phone:863-956-5604
Mailing Address - Fax:
Practice Address - Street 1:526 AVENUE I NW
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-4045
Practice Address - Country:US
Practice Address - Phone:863-521-2999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP 1339171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist