Provider Demographics
NPI:1093358509
Name:NICHOLS, SANDY S
Entity Type:Individual
Prefix:
First Name:SANDY
Middle Name:S
Last Name:NICHOLS
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 1:2302 WINDEMERE WAY
Mailing Address - Street 2:
Mailing Address - City:NEW MARKET
Mailing Address - State:TN
Mailing Address - Zip Code:37820-5251
Mailing Address - Country:US
Mailing Address - Phone:865-851-4525
Mailing Address - Fax:
Practice Address - Street 1:2302 WINDEMERE WAY
Practice Address - Street 2:
Practice Address - City:NEW MARKET
Practice Address - State:TN
Practice Address - Zip Code:37820-5251
Practice Address - Country:US
Practice Address - Phone:865-851-4525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-28
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1000000025336251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1000000025336OtherDEPARTMENT OF MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES