Provider Demographics
NPI:1245349000
Name:NICKLESS, NANCIE L (CRNA)
Entity type:Individual
Prefix:
First Name:NANCIE
Middle Name:L
Last Name:NICKLESS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92 W MILLER ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-2032
Mailing Address - Country:US
Mailing Address - Phone:321-841-4603
Mailing Address - Fax:321-841-4603
Practice Address - Street 1:92 W MILLER ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-2032
Practice Address - Country:US
Practice Address - Phone:321-841-4603
Practice Address - Fax:321-841-4603
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1097752367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL034627600Medicaid
FLARNP1097752OtherMEDICAL LICENSE
FLG1450WMedicare PIN
FL034627600Medicaid
FLG1450VMedicare PIN