Provider Demographics
NPI:1831465269
Name:NICHOLS, LAURA MARIE
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:MARIE
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:MARIE
Other - Last Name:FRAGODT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1775 AURORA CT STE B115
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80045-2536
Mailing Address - Country:US
Mailing Address - Phone:303-724-8695
Mailing Address - Fax:
Practice Address - Street 1:1775 AURORA CT STE B115
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80045-2536
Practice Address - Country:US
Practice Address - Phone:303-724-8695
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-29
Last Update Date:2024-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0072495207RR0500X
390200000X
ND13704207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDN722063Medicare PIN
NDN722064Medicare PIN