Provider Demographics
NPI:1114490026
Name:NICHOLS, KATHY
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:
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 1:226 NAUTICAL DR APT 8
Mailing Address - Street 2:
Mailing Address - City:STURGEON BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54235-2081
Mailing Address - Country:US
Mailing Address - Phone:920-256-1202
Mailing Address - Fax:
Practice Address - Street 1:226 NAUTICAL DR APT 8
Practice Address - Street 2:
Practice Address - City:STURGEON BAY
Practice Address - State:WI
Practice Address - Zip Code:54235-2081
Practice Address - Country:US
Practice Address - Phone:920-256-1202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-03
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care