Provider Demographics
NPI:1427559731
Name:NICHOLSON, REGAN ASHLEY I
Entity Type:Individual
Prefix:
First Name:REGAN
Middle Name:ASHLEY
Last Name:NICHOLSON
Suffix:I
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 1:23864 HIGHWAY 42
Mailing Address - Street 2:
Mailing Address - City:RICHTON
Mailing Address - State:MS
Mailing Address - Zip Code:39476-2620
Mailing Address - Country:US
Mailing Address - Phone:601-410-7456
Mailing Address - Fax:
Practice Address - Street 1:118 COLLEGE DR.
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39406
Practice Address - Country:US
Practice Address - Phone:601-266-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-22
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS390200000X, 2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program