Provider Demographics
NPI:1164407813
Name:NICHOLS, ELIZABETH (OD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:336 W FRONT ST
Mailing Address - Street 2:146
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2204
Mailing Address - Country:US
Mailing Address - Phone:231-941-7788
Mailing Address - Fax:
Practice Address - Street 1:3200 S AIRPORT RD W
Practice Address - Street 2:146
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-8117
Practice Address - Country:US
Practice Address - Phone:231-941-5440
Practice Address - Fax:231-941-0893
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-14
Last Update Date:2016-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIEN002584152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1808535Medicaid
T32832Medicare UPIN
MI1808535Medicaid