Provider Demographics
NPI:1598252892
Name:NICHOLAS, SYDNEY A
Entity Type:Individual
Prefix:
First Name:SYDNEY
Middle Name:A
Last Name:NICHOLAS
Suffix:
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 1:101 BOARDWALK WAY
Mailing Address - Street 2:
Mailing Address - City:ATMAUTLUAK
Mailing Address - State:AK
Mailing Address - Zip Code:99559
Mailing Address - Country:US
Mailing Address - Phone:907-553-5114
Mailing Address - Fax:907-553-5412
Practice Address - Street 1:101 BOARDWALK WAY
Practice Address - Street 2:
Practice Address - City:ATMAUTLUAK
Practice Address - State:AK
Practice Address - Zip Code:99559
Practice Address - Country:US
Practice Address - Phone:907-553-5114
Practice Address - Fax:907-553-5412
Is Sole Proprietor?:No
Enumeration Date:2018-04-23
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker