Provider Demographics
NPI:1336538446
Name:NICHOLES, CYNDI
Entity Type:Individual
Prefix:
First Name:CYNDI
Middle Name:
Last Name:NICHOLES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CYNDI
Other - Middle Name:
Other - Last Name:NICHOLES-SPANN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1657 S GETTY ST
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49442-5872
Mailing Address - Country:US
Mailing Address - Phone:231-343-2753
Mailing Address - Fax:
Practice Address - Street 1:1657 S GETTY ST
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49442-5872
Practice Address - Country:US
Practice Address - Phone:231-343-2753
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-13
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 251E00000X, 253Z00000X
MI171M00000X, 171W00000X, 172V00000X, 251B00000X, 251S00000X, 251X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No171W00000XOther Service ProvidersContractorGroup - Multi-Specialty
No251B00000XAgenciesCase Management
No251E00000XAgenciesHome Health
No251S00000XAgenciesCommunity/Behavioral Health
No251X00000XAgenciesSupports Brokerage
No253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1376866160Medicaid
MI1376866160Medicaid