Provider Demographics
NPI:1407509565
Name:SMIDDY, NICHOLE ANN (RN)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:ANN
Last Name:SMIDDY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1530 HYANNIS DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45503-2016
Mailing Address - Country:US
Mailing Address - Phone:937-561-8875
Mailing Address - Fax:
Practice Address - Street 1:2317 E HOME RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45503-2520
Practice Address - Country:US
Practice Address - Phone:937-390-8060
Practice Address - Fax:937-399-9070
Is Sole Proprietor?:No
Enumeration Date:2022-01-30
Last Update Date:2022-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH390147163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)