Provider Demographics
NPI:1700952413
Name:NICHOLSON, JANIS M (MA,APRN,CS)
Entity Type:Individual
Prefix:MS
First Name:JANIS
Middle Name:M
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:MA,APRN,CS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:278 GOODALE DRIVE
Mailing Address - Street 2:
Mailing Address - City:NEWINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06111-3131
Mailing Address - Country:US
Mailing Address - Phone:860-667-0665
Mailing Address - Fax:860-667-0665
Practice Address - Street 1:278 GOODALE DRIVE
Practice Address - Street 2:
Practice Address - City:NEWINGTON
Practice Address - State:CT
Practice Address - Zip Code:06111-3131
Practice Address - Country:US
Practice Address - Phone:860-667-0665
Practice Address - Fax:860-667-0665
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-27
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTAPRN 000804363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT400000804CT02OtherANTHEM BCBS
CT890000063Medicare ID - Type Unspecified
S48985Medicare UPIN