Provider Demographics
NPI:1417642687
Name:NICHOLS, KENZIE ANN
Entity Type:Individual
Prefix:
First Name:KENZIE
Middle Name:ANN
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KENZIE
Other - Middle Name:ANN
Other - Last Name:GRAVES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:830 SANDERS DR
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFFS
Mailing Address - State:WY
Mailing Address - Zip Code:82082-9755
Mailing Address - Country:US
Mailing Address - Phone:307-575-7835
Mailing Address - Fax:
Practice Address - Street 1:830 SANDERS DR
Practice Address - Street 2:
Practice Address - City:PINE BLUFFS
Practice Address - State:WY
Practice Address - Zip Code:82082-9755
Practice Address - Country:US
Practice Address - Phone:307-575-7835
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-05
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant