Provider Demographics
NPI:1790319572
Name:NICKELL, KELLY NICOLE
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:NICOLE
Last Name:NICKELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:NICOLE
Other - Last Name:SWISHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:62 COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-1115
Mailing Address - Country:US
Mailing Address - Phone:321-843-5851
Mailing Address - Fax:321-843-1673
Practice Address - Street 1:62 COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1115
Practice Address - Country:US
Practice Address - Phone:321-843-5851
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-02
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLAPRN11007463367500000X
FL129422367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program