Provider Demographics
NPI:1912927518
Name:NICHOLS, STACIE R (OD)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:R
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:OD
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 27
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:WA
Mailing Address - Zip Code:99122-0027
Mailing Address - Country:US
Mailing Address - Phone:509-725-2000
Mailing Address - Fax:509-725-4231
Practice Address - Street 1:506 8TH ST.
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:WA
Practice Address - Zip Code:99122
Practice Address - Country:US
Practice Address - Phone:509-725-2000
Practice Address - Fax:509-725-4231
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2010-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00003248152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2025815Medicaid
WAGAB24827Medicare PIN
WAU62305Medicare UPIN