Provider Demographics
NPI:1578847489
Name:NICKOLS, KELLI (APN)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:NICKOLS
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 INGALLS DR
Mailing Address - Street 2:WYMAN GORDON PAVILION- HOME CARE DIVISION
Mailing Address - City:HARVEY
Mailing Address - State:IL
Mailing Address - Zip Code:60426-3558
Mailing Address - Country:US
Mailing Address - Phone:708-915-4649
Mailing Address - Fax:708-915-6357
Practice Address - Street 1:1 INGALLS DR
Practice Address - Street 2:WYMAN GORDON PAVILION- HOME CARE DIVISION
Practice Address - City:HARVEY
Practice Address - State:IL
Practice Address - Zip Code:60426-3558
Practice Address - Country:US
Practice Address - Phone:708-915-4649
Practice Address - Fax:708-915-6357
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-11
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209008896363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily