Provider Demographics
NPI:1255403242
Name:NICHOLS, BEVERLY
Entity type:Individual
Prefix:
First Name:BEVERLY
Middle Name:
Last Name:NICHOLS
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 1:12510 QUEENS BLVD
Mailing Address - Street 2:
Mailing Address - City:KEW GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11415-1519
Mailing Address - Country:US
Mailing Address - Phone:718-459-5592
Mailing Address - Fax:718-459-6047
Practice Address - Street 1:12510 QUEENS BLVD
Practice Address - Street 2:
Practice Address - City:KEW GARDENS
Practice Address - State:NY
Practice Address - Zip Code:11415-1519
Practice Address - Country:US
Practice Address - Phone:718-459-5592
Practice Address - Fax:718-459-6047
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY9569L001364SH0200X, 374U00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No364SH0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistHome Health
No374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01761260Medicaid
NY01761260Medicaid