Provider Demographics
NPI:1265691828
Name:NICHOLSON, TAMARA JO
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:JO
Last Name:NICHOLSON
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 1:4333 BELL RD
Mailing Address - Street 2:UNIT 1610
Mailing Address - City:NEWBURGH
Mailing Address - State:IN
Mailing Address - Zip Code:47630-8177
Mailing Address - Country:US
Mailing Address - Phone:812-202-0659
Mailing Address - Fax:812-490-6259
Practice Address - Street 1:4333 BELL RD
Practice Address - Street 2:UNIT 1610
Practice Address - City:NEWBURGH
Practice Address - State:IN
Practice Address - Zip Code:47630-8177
Practice Address - Country:US
Practice Address - Phone:812-202-0659
Practice Address - Fax:812-490-6259
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-08
Last Update Date:2008-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28077920A156F00000X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No156F00000XEye and Vision Services ProvidersTechnician/Technologist