Basic Information
| Provider Information | |||||||||
| NPI: | 1821655929 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NICHOLSON | ||||||||
| FirstName: | LAURENZCO | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 25487 | ||||||||
| Address2: | |||||||||
| City: | SARASOTA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342772487 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9412025342 | ||||||||
| FaxNumber: | 8552534836 | ||||||||
| Practice Location | |||||||||
| Address1: | 730 GOODLETTE-FRANK RD N STE 100 | ||||||||
| Address2: | |||||||||
| City: | NAPLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341025617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2393512990 | ||||||||
| FaxNumber: | 2393004128 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2019 | ||||||||
| LastUpdateDate: | 11/07/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 15221-I | PR | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | ME156999 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.