Provider Demographics
NPI:1053870337
Name:BRYAN-HENDERSON, NICOLA MARSHA-ANN
Entity type:Individual
Prefix:
First Name:NICOLA
Middle Name:MARSHA-ANN
Last Name:BRYAN-HENDERSON
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 1:955 TOWN CENTER DR STE 100
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-8255
Mailing Address - Country:US
Mailing Address - Phone:386-228-0661
Mailing Address - Fax:386-228-0662
Practice Address - Street 1:955 TOWN CENTER DR STE 100
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-8255
Practice Address - Country:US
Practice Address - Phone:386-228-0661
Practice Address - Fax:386-228-0662
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-18
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11000870363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty