Provider Demographics
NPI:1902867831
Name:NICKEL, TERRI A (DO)
Entity Type:Individual
Prefix:
First Name:TERRI
Middle Name:A
Last Name:NICKEL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:TERRI
Other - Middle Name:A
Other - Last Name:HARMON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 8035
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67208-0035
Mailing Address - Country:US
Mailing Address - Phone:316-689-9135
Mailing Address - Fax:316-689-9667
Practice Address - Street 1:8444 W 21ST ST N
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67205-1752
Practice Address - Country:US
Practice Address - Phone:316-721-9500
Practice Address - Fax:316-721-9574
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2014-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS05-25868207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100292970LMedicaid
003719188OtherMEDICARE
003719188OtherMEDICARE
KS100292970FMedicaid
KS100292970GMedicaid