Provider Demographics
NPI:1275007809
Name:SAMPLE, NELLIE NICOLE (CPHT)
Entity Type:Individual
Prefix:
First Name:NELLIE
Middle Name:NICOLE
Last Name:SAMPLE
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:NELLIE
Other - Middle Name:NICOLE
Other - Last Name:SWOBODA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1402 W CALVERT ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67217-2722
Mailing Address - Country:US
Mailing Address - Phone:316-932-8020
Mailing Address - Fax:
Practice Address - Street 1:5500 E KELLOGG DR
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67218-1607
Practice Address - Country:US
Practice Address - Phone:316-685-2221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-16
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-107167183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician