Provider Demographics
NPI:1891468815
Name:NICHOLS, ISABELL ANN
Entity Type:Individual
Prefix:
First Name:ISABELL
Middle Name:ANN
Last Name:NICHOLS
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 1:69 N MAIN ST APT B215
Mailing Address - Street 2:
Mailing Address - City:CLEARFIELD
Mailing Address - State:UT
Mailing Address - Zip Code:84015-2584
Mailing Address - Country:US
Mailing Address - Phone:775-453-3479
Mailing Address - Fax:
Practice Address - Street 1:69 N MAIN ST APT B215
Practice Address - Street 2:
Practice Address - City:CLEARFIELD
Practice Address - State:UT
Practice Address - Zip Code:84015-2584
Practice Address - Country:US
Practice Address - Phone:775-453-3479
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-26
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12178099-4701225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT12178099-4701OtherDOPL