Provider Demographics
NPI:1346492402
Name:NICHOLSON, TINA M (LPN)
Entity Type:Individual
Prefix:MS
First Name:TINA
Middle Name:M
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MS
Other - First Name:TINA
Other - Middle Name:M
Other - Last Name:NICHOLSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:404 S NEW JERSEY AVE
Mailing Address - Street 2:
Mailing Address - City:WELLSTON
Mailing Address - State:OH
Mailing Address - Zip Code:45692-1810
Mailing Address - Country:US
Mailing Address - Phone:740-384-6138
Mailing Address - Fax:
Practice Address - Street 1:360 HANEY LN S
Practice Address - Street 2:
Practice Address - City:SOUTH SALEM
Practice Address - State:OH
Practice Address - Zip Code:45681-9779
Practice Address - Country:US
Practice Address - Phone:937-981-1847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-21
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH117803 IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse