Provider Demographics
NPI:1053820019
Name:NICHOLS, PATRICIA RENEE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:PATRICIA
Middle Name:RENEE
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:288 ALBEMARLE DR
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:NC
Mailing Address - Zip Code:27527-4218
Mailing Address - Country:US
Mailing Address - Phone:919-631-0708
Mailing Address - Fax:
Practice Address - Street 1:250 NC HIGHWAY 210
Practice Address - Street 2:
Practice Address - City:SMITHFIELD
Practice Address - State:NC
Practice Address - Zip Code:27577-6970
Practice Address - Country:US
Practice Address - Phone:919-300-6507
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-21
Last Update Date:2017-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5947208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation