Provider Demographics
NPI:1629200266
Name:CARTER, NIKKI SHAUNAE (RN)
Entity Type:Individual
Prefix:
First Name:NIKKI
Middle Name:SHAUNAE
Last Name:CARTER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 ELSINORE PL STE 200
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45202-1459
Mailing Address - Country:US
Mailing Address - Phone:513-834-7063
Mailing Address - Fax:
Practice Address - Street 1:580 PARK AVE W
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44906-3722
Practice Address - Country:US
Practice Address - Phone:513-834-7063
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-16
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN. 130071164W00000X
OHRN.460301163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2876928Medicaid