Provider Demographics
NPI:1598305930
Name:NICHOLS, DUSTIN CHRISTINE
Entity type:Individual
Prefix:
First Name:DUSTIN
Middle Name:CHRISTINE
Last Name:NICHOLS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 CHERWOOD LN
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-6334
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1010 CHERWOOD LN
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-6334
Practice Address - Country:US
Practice Address - Phone:304-614-5798
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-14
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11024770367500000X
PARN662461367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered