Provider Demographics
NPI:1073251708
Name:GATES, NICOLE LEE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LEE
Last Name:GATES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:673 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:NELSONVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45764-9745
Mailing Address - Country:US
Mailing Address - Phone:740-517-0977
Mailing Address - Fax:
Practice Address - Street 1:30652 RED ROCK CT
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:OH
Practice Address - Zip Code:43138-9670
Practice Address - Country:US
Practice Address - Phone:740-385-4006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-23
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOPT.007033152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty