Individual
MRS. MADELYN M NICKERSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
6801 4TH ST N, ST PETERSBURG, FL 33702-6844
(727) 822-3238
(727) 823-1278
Mailing address
6801 4TH ST N, ST PETERSBURG, FL 33702-6844
(727) 822-3238
(813) 635-2613
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
PA9109804
FL
363AM0700X
Medical Physician Assistant
Primary
PA9109804
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
019646400
—
FL
Enumeration date
10/23/2016
Last updated
04/12/2023
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