Provider Demographics
NPI:1558327817
Name:NICHOLS, KELLY K (OD, MPH, PHD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:K
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:OD, MPH, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1716 UNIVERSITY BLVD
Mailing Address - Street 2:HPB G080A
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35294-0010
Mailing Address - Country:US
Mailing Address - Phone:205-975-2020
Mailing Address - Fax:205-934-6755
Practice Address - Street 1:1716 UNIVERSITY BLVD
Practice Address - Street 2:HPB G080A
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35294-0010
Practice Address - Country:US
Practice Address - Phone:205-975-2020
Practice Address - Fax:205-934-6755
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2014-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALT-215-TA-976152W00000X
OH4722/T1517152WC0802X
TX7914TG152WC0802X
ALR-222-TA-976152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX112409104Medicaid
TX00E63GMedicare UPIN