Provider Demographics
NPI:1538660766
Name:NICKERSON, ANGELA ROCHELLE (LVN)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:ROCHELLE
Last Name:NICKERSON
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2355 ROCKWELL ST
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77701-8029
Mailing Address - Country:US
Mailing Address - Phone:409-499-9883
Mailing Address - Fax:
Practice Address - Street 1:2355 ROCKWELL ST
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77701-8029
Practice Address - Country:US
Practice Address - Phone:409-499-9883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-22
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX302968164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse