Provider Demographics
NPI:1871820027
Name:NICHOLAS, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
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 1:580 S AIKEN AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15232-1531
Mailing Address - Country:US
Mailing Address - Phone:412-623-3540
Mailing Address - Fax:
Practice Address - Street 1:580 S AIKEN AVE STE 201
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15232-1531
Practice Address - Country:US
Practice Address - Phone:412-623-3540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-09
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA054064363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical