Provider Demographics
NPI:1902260292
Name:GUTIERREZ, NICHOLAS (ATC, LAT)
Entity Type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:
Last Name:GUTIERREZ
Suffix:
Gender:M
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 1:909 SANTA ROSA BLVD UNIT 519
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32548-5900
Mailing Address - Country:US
Mailing Address - Phone:850-896-7413
Mailing Address - Fax:
Practice Address - Street 1:449 W 23RD ST
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4507
Practice Address - Country:US
Practice Address - Phone:850-769-8341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-12
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL 43672255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer