Provider Demographics
NPI:1336197078
Name:NICKELS, KATRINA (MD)
Entity Type:Individual
Prefix:DR
First Name:KATRINA
Middle Name:
Last Name:NICKELS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KATRINA
Other - Middle Name:
Other - Last Name:SANDOVAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2312 ALEXANDRIA DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-3229
Mailing Address - Country:US
Mailing Address - Phone:859-276-5344
Mailing Address - Fax:859-296-0362
Practice Address - Street 1:800 ROSE ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-3229
Practice Address - Country:US
Practice Address - Phone:859-257-1000
Practice Address - Fax:859-257-1342
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY39009207R00000X, 207RA0401X, 207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64101462Medicaid
KY64101462Medicaid
KY576319Medicare PIN