Provider Demographics
NPI:1194065870
Name:NICHOLS, ISIDORA (ATC, LAT)
Entity type:Individual
Prefix:
First Name:ISIDORA
Middle Name:
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9765 SOUTHBROOK DR
Mailing Address - Street 2:APT. 2203
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-0459
Mailing Address - Country:US
Mailing Address - Phone:863-712-0988
Mailing Address - Fax:
Practice Address - Street 1:115 BARTRAM OAKS WALK
Practice Address - Street 2:STE. 104
Practice Address - City:SAINT JOHNS
Practice Address - State:FL
Practice Address - Zip Code:32259-3243
Practice Address - Country:US
Practice Address - Phone:904-240-0471
Practice Address - Fax:904-240-0471
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-18
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL 28542255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer