Provider Demographics
NPI:1295991313
Name:NICHOLS, KATHERINE MARIE (MD)
Entity type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:MARIE
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MALLARD CREEK RD
Mailing Address - Street 2:STE 406
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4194
Mailing Address - Country:US
Mailing Address - Phone:502-895-4607
Mailing Address - Fax:502-895-4586
Practice Address - Street 1:100 MALLARD CREEK RD
Practice Address - Street 2:STE 406
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4194
Practice Address - Country:US
Practice Address - Phone:502-895-4607
Practice Address - Fax:502-895-4586
Is Sole Proprietor?:No
Enumeration Date:2008-07-29
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY44258208000000X, 2080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201028960Medicaid
KY7100164170Medicaid
KYK006340Medicare PIN
KY7100164170Medicaid
IN201028960Medicaid