Provider Demographics
NPI:1316555329
Name:NICKLAS, MADELINE (CPSS)
Entity Type:Individual
Prefix:
First Name:MADELINE
Middle Name:
Last Name:NICKLAS
Suffix:
Gender:F
Credentials:CPSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6705
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39506-6705
Mailing Address - Country:US
Mailing Address - Phone:228-865-1330
Mailing Address - Fax:
Practice Address - Street 1:1600 BROAD AVE
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-3603
Practice Address - Country:US
Practice Address - Phone:228-863-1132
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-15
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist