Provider Demographics
NPI:1093479701
Name:NICHOLSON, ANDRA L SR
Entity Type:Individual
Prefix:MR
First Name:ANDRA
Middle Name:L
Last Name:NICHOLSON
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1724 W CLARKE ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53206-2030
Mailing Address - Country:US
Mailing Address - Phone:414-763-9892
Mailing Address - Fax:414-763-0531
Practice Address - Street 1:1724 W CLARKE ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53206-2030
Practice Address - Country:US
Practice Address - Phone:414-763-9892
Practice Address - Fax:414-763-0531
Is Sole Proprietor?:No
Enumeration Date:2021-10-28
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIN242-0126-3466-07172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver