1679119036 NPI number — MRS. CARLY ANNE NICHOLS OTD OTR/L

Table of content: MRS. CARLY ANNE NICHOLS OTD OTR/L (NPI 1679119036)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679119036 NPI number — MRS. CARLY ANNE NICHOLS OTD OTR/L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NICHOLS
Provider First Name:
CARLY
Provider Middle Name:
ANNE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
OTD OTR/L
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:
1679119036
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/07/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1620 HIGHWAY 11 N STE C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PICAYUNE
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39466-2070
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1601 CENTRAL AVE W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WIGGINS
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39577-2401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-716-3196
Provider Business Practice Location Address Fax Number:
601-974-9919
Provider Enumeration Date:
11/20/2019

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: 225X00000X , with the licence number:  OT-4116 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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