Provider Demographics
NPI:1225513138
Name:NICHOLSON, KARLTON I (PMHMP)
Entity Type:Individual
Prefix:MR
First Name:KARLTON
Middle Name:
Last Name:NICHOLSON
Suffix:I
Gender:M
Credentials:PMHMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16336 W MESQUITE DR
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-4648
Mailing Address - Country:US
Mailing Address - Phone:623-693-2126
Mailing Address - Fax:
Practice Address - Street 1:16336 W MESQUITE DR
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-4648
Practice Address - Country:US
Practice Address - Phone:623-693-2126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-26
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN177663363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health