Provider Demographics
NPI:1710607106
Name:NICHOLAS, SHARELLE
Entity Type:Individual
Prefix:
First Name:SHARELLE
Middle Name:
Last Name:NICHOLAS
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 1:1853 PEARLAND PKWY STE 123
Mailing Address - Street 2:PMB 1037
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77581-8864
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4502 RIVERSTONE BLVD STE 1002
Practice Address - Street 2:
Practice Address - City:MISSOURI CITY
Practice Address - State:TX
Practice Address - Zip Code:77459-5209
Practice Address - Country:US
Practice Address - Phone:773-882-0962
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-29
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT135074225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty