Provider Demographics
NPI:1801173398
Name:KING, NICHOLE DAWN
Entity type:Individual
Prefix:
First Name:NICHOLE
Middle Name:DAWN
Last Name:KING
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 1:2676 CHARLESTOWN RD STE 2A
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47150-2574
Mailing Address - Country:US
Mailing Address - Phone:812-725-7034
Mailing Address - Fax:
Practice Address - Street 1:2676 CHARLESTOWN RD STE 2A
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-2574
Practice Address - Country:US
Practice Address - Phone:812-725-7034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-10
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3007229363LF0000X
IN71003843A363LP2300X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
1799231OtherWELLCARE
IN201324120Medicaid
CS1817000344OtherCARESOURCE
201324120OtherMDWISE
2017085OtherSIHO
000001143240OtherANTHEM
6514104OtherUHC
9086917OtherAETNA
9912737OtherCIGNA