Provider Demographics
NPI:1134762032
Name:NICHOLS, SHANDA KAY (LMT)
Entity type:Individual
Prefix:
First Name:SHANDA
Middle Name:KAY
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1810 WOODFIELD DR STE 201
Mailing Address - Street 2:
Mailing Address - City:SAVOY
Mailing Address - State:IL
Mailing Address - Zip Code:61874-9377
Mailing Address - Country:US
Mailing Address - Phone:217-419-6622
Mailing Address - Fax:
Practice Address - Street 1:1810 WOODFIELD DR STE 201
Practice Address - Street 2:
Practice Address - City:SAVOY
Practice Address - State:IL
Practice Address - Zip Code:61874-9377
Practice Address - Country:US
Practice Address - Phone:217-419-6622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-23
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.020079225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist