Provider Demographics
NPI:1649094665
Name:NICHOLAS, SHANTAR ORNELLA I
Entity type:Individual
Prefix:
First Name:SHANTAR
Middle Name:ORNELLA
Last Name:NICHOLAS
Suffix:I
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5770 NW 60TH AVE APT E103
Mailing Address - Street 2:
Mailing Address - City:TAMARAC
Mailing Address - State:FL
Mailing Address - Zip Code:33319-2446
Mailing Address - Country:US
Mailing Address - Phone:954-901-9359
Mailing Address - Fax:
Practice Address - Street 1:6412 N UNIVERSITY DR STE 117
Practice Address - Street 2:
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33321-4002
Practice Address - Country:US
Practice Address - Phone:954-991-9359
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-15
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist