1972501138 NPI number — HEIDI NICHOLS CNP

Table of content: HEIDI NICHOLS CNP (NPI 1972501138)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972501138 NPI number — HEIDI NICHOLS CNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NICHOLS
Provider First Name:
HEIDI
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CNP
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:
1972501138
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/21/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4235 SECOR RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TOLEDO
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43623-4231
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-479-5605
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
777 KIMOLE LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ADRIAN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49221-1478
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-263-3393
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/12/2005

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: 363LF0000X , with the licence number:  4704140375 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0355456 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: P0024950 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0N11220 . This is a "GROUP MEDICARE PIN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com