Provider Demographics
NPI:1679886162
Name:NICOL, KELLY S (LPN)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:S
Last Name:NICOL
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5446 STATE ROUTE 73
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OH
Mailing Address - Zip Code:45133-9004
Mailing Address - Country:US
Mailing Address - Phone:937-763-2114
Mailing Address - Fax:
Practice Address - Street 1:5446 STATE ROUTE 73
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OH
Practice Address - Zip Code:45133-9004
Practice Address - Country:US
Practice Address - Phone:937-763-2114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-26
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN. 129950 IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse