Provider Demographics
NPI:1609036045
Name:NICHOLS, DEBORAH (IP)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:IP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:390 SHAWNEE RD
Mailing Address - Street 2:
Mailing Address - City:OTWAY
Mailing Address - State:OH
Mailing Address - Zip Code:45657-8886
Mailing Address - Country:US
Mailing Address - Phone:937-544-4017
Mailing Address - Fax:
Practice Address - Street 1:390 SHAWNEE RD
Practice Address - Street 2:
Practice Address - City:OTWAY
Practice Address - State:OH
Practice Address - Zip Code:45657-8886
Practice Address - Country:US
Practice Address - Phone:937-544-4017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-10
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2684528374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2684528Medicaid