Provider Demographics
NPI:1407054745
Name:NICHOLS, KENSLEY (MD)
Entity Type:Individual
Prefix:
First Name:KENSLEY
Middle Name:
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2215 LANDOVER PL
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24501-2115
Mailing Address - Country:US
Mailing Address - Phone:434-947-3944
Mailing Address - Fax:434-544-2337
Practice Address - Street 1:2215 LANDOVER PL
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-2115
Practice Address - Country:US
Practice Address - Phone:434-947-3944
Practice Address - Fax:434-544-2337
Is Sole Proprietor?:No
Enumeration Date:2007-07-09
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT048960208M00000X
CT48960207RI0200X
VA0101261116207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT048960OtherCT LICENSE
CT1407054745Medicaid
CT1407054745Medicaid
CT048960OtherCT LICENSE