Provider Demographics
NPI:1811366602
Name:NICHOLSON, ANITA L (APRN)
Entity Type:Individual
Prefix:
First Name:ANITA
Middle Name:L
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:ANITA
Other - Middle Name:L
Other - Last Name:KELLOWAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:333 BORTHWICK AVE
Mailing Address - Street 2:MOB 402
Mailing Address - City:PORTSMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03801-7128
Mailing Address - Country:US
Mailing Address - Phone:603-559-4111
Mailing Address - Fax:603-559-4110
Practice Address - Street 1:333 BORTHWICK AVE
Practice Address - Street 2:MOB 402
Practice Address - City:PORTSMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03801-7128
Practice Address - Country:US
Practice Address - Phone:603-559-4111
Practice Address - Fax:603-559-4110
Is Sole Proprietor?:No
Enumeration Date:2015-09-22
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH054231-23363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3102254Medicaid
ME1811366602Medicaid
NH3102254Medicaid
NHRAILROAD P01705190Medicare PIN