Provider Demographics
NPI:1457352122
Name:NICHOLS, MICHELLE R (MD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:R
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:PO BOX 791
Mailing Address - Street 2:213 C EAST MARION ST
Mailing Address - City:PILOT MTN
Mailing Address - State:NC
Mailing Address - Zip Code:27041-0791
Mailing Address - Country:US
Mailing Address - Phone:336-368-1070
Mailing Address - Fax:336-368-1071
Practice Address - Street 1:213C E MARION ST
Practice Address - Street 2:
Practice Address - City:PILOT MTN
Practice Address - State:NC
Practice Address - Zip Code:27041-8535
Practice Address - Country:US
Practice Address - Phone:336-368-1070
Practice Address - Fax:336-368-1071
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9801727207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89129N0Medicaid
NCH29251Medicare UPIN
NC2281090AMedicare ID - Type Unspecified