Provider Demographics
NPI:1972501138
Name:NICHOLS, HEIDI (CNP)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4235 SECOR RD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43623-4231
Mailing Address - Country:US
Mailing Address - Phone:419-479-5605
Mailing Address - Fax:
Practice Address - Street 1:777 KIMOLE LN
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-1478
Practice Address - Country:US
Practice Address - Phone:517-263-3393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704140375363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0355456Medicaid
P0024950OtherRAILROAD MEDICARE
MI0N11220OtherGROUP MEDICARE PIN
OH0355456Medicaid
P90334Medicare UPIN