Provider Demographics
NPI:1205317237
Name:NICHOLS, CARLENE MAY (LVN)
Entity type:Individual
Prefix:MISS
First Name:CARLENE
Middle Name:MAY
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3211 BROKEN BOUGH DR
Mailing Address - Street 2:
Mailing Address - City:MISSOURI CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77459-2542
Mailing Address - Country:US
Mailing Address - Phone:832-305-1166
Mailing Address - Fax:281-969-8137
Practice Address - Street 1:4502 RIVERSTONE BLVD
Practice Address - Street 2:
Practice Address - City:MISSOURI CITY
Practice Address - State:TX
Practice Address - Zip Code:77459-5204
Practice Address - Country:US
Practice Address - Phone:281-903-7613
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-28
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX328702164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse