Provider Demographics
NPI:1225652654
Name:NICHOLS, KYLE WAYNE (OD)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:WAYNE
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3046 KNIGHTS RD
Mailing Address - Street 2:
Mailing Address - City:BENSALEM
Mailing Address - State:PA
Mailing Address - Zip Code:19020-2815
Mailing Address - Country:US
Mailing Address - Phone:215-639-4500
Mailing Address - Fax:215-604-0355
Practice Address - Street 1:111 ASH ST
Practice Address - Street 2:
Practice Address - City:TUNKHANNOCK
Practice Address - State:PA
Practice Address - Zip Code:18657-6920
Practice Address - Country:US
Practice Address - Phone:570-575-6125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-01
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG003675152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist