Provider Demographics
NPI:1144891763
Name:VAN NORTWICK, NIKALA RAY
Entity type:Individual
Prefix:
First Name:NIKALA
Middle Name:RAY
Last Name:VAN NORTWICK
Suffix:
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 1:2798 COTTONWOOD CT
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33761-3809
Mailing Address - Country:US
Mailing Address - Phone:727-945-2226
Mailing Address - Fax:
Practice Address - Street 1:2798 COTTONWOOD CT
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33761-3809
Practice Address - Country:US
Practice Address - Phone:727-945-2226
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-06
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA18388224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty