Provider Demographics
NPI:1952586687
Name:WALSH, NICHOLA DELANA (LPN)
Entity Type:Individual
Prefix:MRS
First Name:NICHOLA
Middle Name:DELANA
Last Name:WALSH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5937 STATE ROUTE 314
Mailing Address - Street 2:
Mailing Address - City:FREDERICKTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:43019-9225
Mailing Address - Country:US
Mailing Address - Phone:419-768-4043
Mailing Address - Fax:419-768-4043
Practice Address - Street 1:5937 STATE ROUTE 314
Practice Address - Street 2:
Practice Address - City:FREDERICKTOWN
Practice Address - State:OH
Practice Address - Zip Code:43019-9225
Practice Address - Country:US
Practice Address - Phone:419-768-4043
Practice Address - Fax:419-768-4043
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-31
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN100974164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2799637Medicaid