Provider Demographics
NPI:1073262028
Name:NICKLES, CHRISTINE
Entity Type:Individual
Prefix:MS
First Name:CHRISTINE
Middle Name:
Last Name:NICKLES
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 1:216 8TH ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70501-7163
Mailing Address - Country:US
Mailing Address - Phone:853-970-2909
Mailing Address - Fax:225-831-9664
Practice Address - Street 1:216 8TH ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70501-7163
Practice Address - Country:US
Practice Address - Phone:985-397-0290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-18
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1171824Medicaid