Provider Demographics
NPI:1770103780
Name:NICHOLS, KACY LEIGH (DO)
Entity type:Individual
Prefix:
First Name:KACY
Middle Name:LEIGH
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:DO
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 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:885 SUMMIT CROSSING PLACE
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-2193
Practice Address - Country:US
Practice Address - Phone:704-316-4979
Practice Address - Fax:704-316-4978
Is Sole Proprietor?:No
Enumeration Date:2020-04-20
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2022-02982207Q00000X
NC260755207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine