Provider Demographics
NPI:1760170716
Name:NICKERSON, SHAYLA
Entity Type:Individual
Prefix:
First Name:SHAYLA
Middle Name:
Last Name:NICKERSON
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 1:1739 STRINGTOWN RD # 1029
Mailing Address - Street 2:
Mailing Address - City:GROVE CITY
Mailing Address - State:OH
Mailing Address - Zip Code:43123-9125
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:159 N OGDEN AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43204-3313
Practice Address - Country:US
Practice Address - Phone:614-897-2638
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-27
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker