Provider Demographics
NPI:1073380184
Name:NICHOLAS, DYLAN BLADE (KCPSS)
Entity Type:Individual
Prefix:
First Name:DYLAN
Middle Name:BLADE
Last Name:NICHOLAS
Suffix:
Gender:M
Credentials:KCPSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 KENSINGTON WAY
Mailing Address - Street 2:
Mailing Address - City:CAMPBELLSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42718-9548
Mailing Address - Country:US
Mailing Address - Phone:270-849-8199
Mailing Address - Fax:
Practice Address - Street 1:451 QUISENBERRY RD
Practice Address - Street 2:
Practice Address - City:CAMPBELLSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42718-8005
Practice Address - Country:US
Practice Address - Phone:270-937-4898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-08
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1208146175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist