Provider Demographics
NPI:1154483501
Name:NICHOLS, KRISTIE BETH (MD)
Entity Type:Individual
Prefix:
First Name:KRISTIE
Middle Name:BETH
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 E HECTOR ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:CONSHOHOCKEN
Mailing Address - State:PA
Mailing Address - Zip Code:19428-2374
Mailing Address - Country:US
Mailing Address - Phone:610-828-2608
Mailing Address - Fax:610-828-0102
Practice Address - Street 1:1100 E HECTOR ST
Practice Address - Street 2:SUITE 105
Practice Address - City:CONSHOHOCKEN
Practice Address - State:PA
Practice Address - Zip Code:19428-2374
Practice Address - Country:US
Practice Address - Phone:610-828-2608
Practice Address - Fax:610-828-0102
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD435394207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA158009HK1Medicare PIN
PA232359401OtherMLHC TIN #
PA440771OtherMLHC MEDICARE AA #
PA102323166Medicaid