Provider Demographics
NPI:1336817071
Name:NICKELSON, LINDA
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:NICKELSON
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 1:480 EVERETT PL
Mailing Address - Street 2:
Mailing Address - City:ROMNEY
Mailing Address - State:WV
Mailing Address - Zip Code:26757-1332
Mailing Address - Country:US
Mailing Address - Phone:304-822-5784
Mailing Address - Fax:
Practice Address - Street 1:480 EVERETT PL
Practice Address - Street 2:
Practice Address - City:ROMNEY
Practice Address - State:WV
Practice Address - Zip Code:26757-1332
Practice Address - Country:US
Practice Address - Phone:304-822-5784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-30
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker