Provider Demographics
NPI:1568865194
Name:MCNICHOL, ELIZABETH (FNP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:MCNICHOL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:DALTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:3455 MAIN ST STE 5
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01107-1142
Mailing Address - Country:US
Mailing Address - Phone:413-733-9600
Mailing Address - Fax:
Practice Address - Street 1:3455 MAIN ST STE 5
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01107-1142
Practice Address - Country:US
Practice Address - Phone:413-733-9600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-26
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA263999363L00000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAS400240769OtherMEDICARE PTAN