Provider Demographics
NPI:1336872142
Name:NICHOLS, GREGORY ANDREW (LMT)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:ANDREW
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4300 S HWY 27 STE 205B
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-8067
Mailing Address - Country:US
Mailing Address - Phone:407-949-0214
Mailing Address - Fax:
Practice Address - Street 1:4300 S HWY 27 STE 205B
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-8067
Practice Address - Country:US
Practice Address - Phone:407-949-0214
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-08
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA100421225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty