Provider Demographics
NPI:1083259519
Name:NICHOLS, JUDY LYNN (NEMT)
Entity Type:Individual
Prefix:MS
First Name:JUDY
Middle Name:LYNN
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:NEMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2311 W MADDOX RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72076-8771
Mailing Address - Country:US
Mailing Address - Phone:925-695-6038
Mailing Address - Fax:
Practice Address - Street 1:2311 W MADDOX RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72076-8771
Practice Address - Country:US
Practice Address - Phone:925-695-6038
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-07
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX29160381172A00000X
TX172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR965208Medicaid