Provider Demographics
NPI:1023761368
Name:CHURCHILL, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:CHURCHILL
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 1:4115 S SEMORAN BLVD APT 9
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32822-2427
Mailing Address - Country:US
Mailing Address - Phone:561-410-3896
Mailing Address - Fax:
Practice Address - Street 1:1107 MABBETTE ST
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-5161
Practice Address - Country:US
Practice Address - Phone:407-201-8079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-27
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSI48442355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant