Provider Demographics
NPI:1295761930
Name:NICKERSON, BRIAN J (ATC)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:J
Last Name:NICKERSON
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 AVERY LAKE DR
Mailing Address - Street 2:
Mailing Address - City:WINTER SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32708-5191
Mailing Address - Country:US
Mailing Address - Phone:407-971-1883
Mailing Address - Fax:407-835-8878
Practice Address - Street 1:100 W GORE ST
Practice Address - Street 2:SUITE 204
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1044
Practice Address - Country:US
Practice Address - Phone:407-835-8818
Practice Address - Fax:407-835-8878
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL 962255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer