Provider Demographics
NPI:1891554283
Name:NICKLES, MCKENZIE GIBSON
Entity Type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:GIBSON
Last Name:NICKLES
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 1:240 HOSPITAL RD
Mailing Address - Street 2:
Mailing Address - City:WHITESBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41858-7627
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:240 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:WHITESBURG
Practice Address - State:KY
Practice Address - Zip Code:41858-7627
Practice Address - Country:US
Practice Address - Phone:606-633-3500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-18
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program