Provider Demographics
NPI:1700101318
Name:NICHOLSON, TINA MAREI
Entity Type:Individual
Prefix:MRS
First Name:TINA
Middle Name:MAREI
Last Name:NICHOLSON
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:PO BOX 418
Mailing Address - Street 2:13 LOVELL DRIVE
Mailing Address - City:GILSUM
Mailing Address - State:NH
Mailing Address - Zip Code:03448-0418
Mailing Address - Country:US
Mailing Address - Phone:603-352-7863
Mailing Address - Fax:
Practice Address - Street 1:22 NORTH ST
Practice Address - Street 2:
Practice Address - City:JAFFREY
Practice Address - State:NH
Practice Address - Zip Code:03452-5340
Practice Address - Country:US
Practice Address - Phone:603-532-2426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-07
Last Update Date:2010-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH032817-24376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide