Provider Demographics
NPI:1538362843
Name:NICHOLS, CORINNE R (AP, DOM)
Entity type:Individual
Prefix:
First Name:CORINNE
Middle Name:R
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:AP, DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11850 DR MARTIN LUTHER KING JR ST N
Mailing Address - Street 2:UNIT 21203
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33716-1619
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3611 W HILLSBOROUGH AVE
Practice Address - Street 2:SUITE 212
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-5757
Practice Address - Country:US
Practice Address - Phone:813-319-2223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP2247171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist