1356309710 NPI number — DR. KIMBERLEY R NICHOLS MD

Table of content: DR. KIMBERLEY R NICHOLS MD (NPI 1356309710)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356309710 NPI number — DR. KIMBERLEY R NICHOLS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NICHOLS
Provider First Name:
KIMBERLEY
Provider Middle Name:
R
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356309710
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/26/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
143 W FRANKLIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHAPEL HILL
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27516-2539
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-966-8596
Provider Business Mailing Address Fax Number:
919-843-5515

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 MANNING DR.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHAPEL HILL
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27599-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-966-8596
Provider Business Practice Location Address Fax Number:
919-843-5515
Provider Enumeration Date:
05/03/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X , with the licence number:  0101238564 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208VP0000X , with the licence number: 0101238564 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207L00000X , with the licence number: 200401424 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 5917900 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 010214360 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".