MEDICARE: ANGEL NICHOLS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant

General Provider Information

NPI Number	:	1013730597
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANGEL NICHOLS

Provider Business Mailing Address
First Line	:	1607 KARR RD
Second Line	:
City	:	DETROIT
State	:	AL
Zip	:	35552-2817
Country	:	US
Telephone Number	:	205-431-5544
Fax Number	:

Provider Business Practice Location Address
First Line	:	1607 KARR RD
Second Line	:
City	:	DETROIT
State	:	AL
Zip	:	35552-2817
Country	:	US
Telephone Number	:	205-431-5544
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/04/2024
Last Update Date	:	11/04/2024

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Directions to “ ANGEL NICHOLS ” Practice Location

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