Provider Demographics
NPI:1811160633
Name:NUCKOLS, ANGELA DAWN (MA)
Entity type:Individual
Prefix:MS
First Name:ANGELA
Middle Name:DAWN
Last Name:NUCKOLS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62 PAYNES FORD RD
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25405-5799
Mailing Address - Country:US
Mailing Address - Phone:304-262-1576
Mailing Address - Fax:
Practice Address - Street 1:401 S QUEEN ST
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401-3233
Practice Address - Country:US
Practice Address - Phone:304-264-5055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-12
Last Update Date:2008-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV7403022000Medicaid