Provider Demographics
NPI:1104159904
Name:NICHOLS, LEILA KEEL (CNM)
Entity type:Individual
Prefix:MRS
First Name:LEILA
Middle Name:KEEL
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 400
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38302-0400
Mailing Address - Country:US
Mailing Address - Phone:731-422-0213
Mailing Address - Fax:731-425-5743
Practice Address - Street 1:2863 HIGHWAY 45 BYP
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-3618
Practice Address - Country:US
Practice Address - Phone:731-660-8300
Practice Address - Fax:731-660-8301
Is Sole Proprietor?:No
Enumeration Date:2009-09-10
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN13090207V00000X
TNAPN14288367A00000X
WVAPRN90339MIDWIFE367A00000X
TN14288367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3380640OtherMEDICARE GROUP
TN3380640OtherMEDICAID GROUP
TN1525515Medicaid
TN1525515Medicaid
TN3380640OtherMEDICAID GROUP
TN1525515Medicaid
TN103I425071Medicare PIN
TN3380640OtherMEDICARE GROUP
WVQ49163AMedicare PIN