Provider Demographics
NPI:1609082486
Name:NICKENS, NICOLE DENISE (MSN, A-GPNP-BC,)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:DENISE
Last Name:NICKENS
Suffix:
Gender:F
Credentials:MSN, A-GPNP-BC,
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:DENIES
Other - Last Name:NICKENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSN, A-GPNP-BC,
Mailing Address - Street 1:30841 EUCLID AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:WILLOUGHBY
Mailing Address - State:OH
Mailing Address - Zip Code:44094-3100
Mailing Address - Country:US
Mailing Address - Phone:216-441-2496
Mailing Address - Fax:216-453-5966
Practice Address - Street 1:30841 EUCLID AVE STE 103
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-3100
Practice Address - Country:US
Practice Address - Phone:216-441-2496
Practice Address - Fax:216-453-5966
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCNP020745207RA0401X
OHAPRN.CNP.020745363L00000X
OHRN346914163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0223866Medicaid
OH2462777Medicaid
OH1609082486Medicaid
OH1609082486Medicaid