Provider Demographics
NPI:1184180531
Name:GRIFFITH, NICOLE LYNN
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LYNN
Last Name:GRIFFITH
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 1:133 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45459-4620
Mailing Address - Country:US
Mailing Address - Phone:937-433-3931
Mailing Address - Fax:
Practice Address - Street 1:133 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-4620
Practice Address - Country:US
Practice Address - Phone:937-433-3931
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-11
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1891226262Medicaid