Provider Demographics
NPI:1760053433
Name:NICHOLS, PAUL ANTHONY (RN)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:ANTHONY
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:747 18TH ST
Mailing Address - Street 2:
Mailing Address - City:OTSEGO
Mailing Address - State:MI
Mailing Address - Zip Code:49078-9752
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1910 SHAFFER ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048-1604
Practice Address - Country:US
Practice Address - Phone:844-206-8738
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-05
Last Update Date:2021-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704376708163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse