Provider Demographics
NPI:1114434503
Name:NIMMO, NICHOLE
Entity Type:Individual
Prefix:MRS
First Name:NICHOLE
Middle Name:
Last Name:NIMMO
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 1:707 COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:NC
Mailing Address - Zip Code:28328-3503
Mailing Address - Country:US
Mailing Address - Phone:910-592-4507
Mailing Address - Fax:
Practice Address - Street 1:707 COLLEGE ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NC
Practice Address - Zip Code:28328-3503
Practice Address - Country:US
Practice Address - Phone:910-592-4507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-07
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NCP0142021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty