Provider Demographics
NPI:1396201794
Name:NICHOLES, REGINA RENEE
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:RENEE
Last Name:NICHOLES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:178 BAKER RD
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:LA
Mailing Address - Zip Code:70443-4742
Mailing Address - Country:US
Mailing Address - Phone:985-474-2114
Mailing Address - Fax:
Practice Address - Street 1:115 W OAK ST
Practice Address - Street 2:
Practice Address - City:AMITE
Practice Address - State:LA
Practice Address - Zip Code:70422-2715
Practice Address - Country:US
Practice Address - Phone:985-474-2114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-11
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA20100159164W00000X
3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No164W00000XNursing Service ProvidersLicensed Practical Nurse