Provider Demographics
NPI:1861184533
Name:NICHOLSON, LILLIAN (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:LILLIAN
Middle Name:
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:LILLIAN
Other - Middle Name:
Other - Last Name:MANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1286 FLORIDA AVE S STE 1
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-2400
Mailing Address - Country:US
Mailing Address - Phone:213-636-7780
Mailing Address - Fax:321-636-1152
Practice Address - Street 1:1286 FLORIDA AVE S STE 1
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-2400
Practice Address - Country:US
Practice Address - Phone:321-636-7780
Practice Address - Fax:321-636-1152
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-22
Last Update Date:2025-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9117659363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant