Provider Demographics
NPI:1639130552
Name:NICKELL, GRETCHEN LEIGH (DO)
Entity Type:Individual
Prefix:DR
First Name:GRETCHEN
Middle Name:LEIGH
Last Name:NICKELL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:GRETCHEN
Other - Middle Name:LEIGH
Other - Last Name:GALLOWAY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 645409
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15264-5252
Mailing Address - Country:US
Mailing Address - Phone:330-386-6442
Mailing Address - Fax:330-386-3660
Practice Address - Street 1:123 W 6TH ST
Practice Address - Street 2:
Practice Address - City:EAST LIVERPOOL
Practice Address - State:OH
Practice Address - Zip Code:43920-2921
Practice Address - Country:US
Practice Address - Phone:330-385-7170
Practice Address - Fax:330-385-6359
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34007999G207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2404204Medicaid
280861OtherANTHEM
H86293Medicare UPIN
OH2404204Medicaid