Provider Demographics
NPI:1841413499
Name:NICHOLLS, BONNIE SUE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:BONNIE
Middle Name:SUE
Last Name:NICHOLLS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10406 KRISTEN PARK DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32832-5824
Mailing Address - Country:US
Mailing Address - Phone:407-273-0768
Mailing Address - Fax:
Practice Address - Street 1:100 W GORE ST
Practice Address - Street 2:SUITE 301
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1044
Practice Address - Country:US
Practice Address - Phone:407-481-8861
Practice Address - Fax:407-481-8862
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA 20215225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant