Provider Demographics
NPI:1619540507
Name:NICHOLSON, LAUREN AMY (NP-C)
Entity Type:Individual
Prefix:MRS
First Name:LAUREN
Middle Name:AMY
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4822 KELLY AVE
Mailing Address - Street 2:
Mailing Address - City:ROOTSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44272-9286
Mailing Address - Country:US
Mailing Address - Phone:440-334-4392
Mailing Address - Fax:
Practice Address - Street 1:626 34TH ST NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44709-2943
Practice Address - Country:US
Practice Address - Phone:330-492-7171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-20
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAG06210248363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care