Provider Demographics
NPI:1942618541
Name:NICKSON, EDNA MAE
Entity Type:Individual
Prefix:
First Name:EDNA
Middle Name:MAE
Last Name:NICKSON
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 1:537 E COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:ALLIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:44601-2550
Mailing Address - Country:US
Mailing Address - Phone:330-823-0465
Mailing Address - Fax:
Practice Address - Street 1:537 E COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:ALLIANCE
Practice Address - State:OH
Practice Address - Zip Code:44601-2550
Practice Address - Country:US
Practice Address - Phone:330-823-0465
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-27
Last Update Date:2014-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2829505251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2829505Medicaid