Provider Demographics
NPI:1689379067
Name:NICKELL, SARA SUE ELLEN
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:SUE ELLEN
Last Name:NICKELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2824 EDGE RD
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:OK
Mailing Address - Zip Code:73439-8880
Mailing Address - Country:US
Mailing Address - Phone:580-624-0774
Mailing Address - Fax:
Practice Address - Street 1:520 POINTE PARKWAY BLVD
Practice Address - Street 2:
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099-0600
Practice Address - Country:US
Practice Address - Phone:405-805-6403
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-04
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK106S00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK23264761OtherSARA NICKELL