Provider Demographics
NPI:1700563038
Name:SMITH, NICKOLAS J (NP)
Entity Type:Individual
Prefix:
First Name:NICKOLAS
Middle Name:J
Last Name:SMITH
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:847 BALLARD ST APT L
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32701-5773
Mailing Address - Country:US
Mailing Address - Phone:954-226-8888
Mailing Address - Fax:
Practice Address - Street 1:250 W 5TH ST
Practice Address - Street 2:
Practice Address - City:HANFORD
Practice Address - State:CA
Practice Address - Zip Code:93230-5029
Practice Address - Country:US
Practice Address - Phone:877-960-3426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-29
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11027037363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily