Provider Demographics
NPI:1285665570
Name:NICKLES, JULIE PANDORA (DO)
Entity Type:Individual
Prefix:DR
First Name:JULIE
Middle Name:PANDORA
Last Name:NICKLES
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-9800
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:
Practice Address - Street 1:175 S WILKES BARRE BLVD
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702-5040
Practice Address - Country:US
Practice Address - Phone:570-829-2621
Practice Address - Fax:570-823-4332
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS004879L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA02713300OtherCAPITAL BLUE CROSS
PA0459530OtherAETNA
PA22143OtherGEISINGER HEALTH PLAN
PA431452OtherCAPITAL BLUE SHIELD
PA2713300OtherKHP CENTRAL
PA431452OtherCAPITAL BLUE SHIELD
PAD98789Medicare UPIN