Healthcare Provider Details

I. General information

NPI: 1093773285
Provider Name (Legal Business Name): KATRINA ANNE NICHOLS OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 09/22/2025
Certification Date: 09/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

549 E 10TH ST
DOUGLAS AZ
85607-2009
US

IV. Provider business mailing address

14615 E CIRCLE L RANCH PL
VAIL AZ
85641-8939
US

V. Phone/Fax

Practice location:
  • Phone: 520-364-3892
  • Fax: 520-805-4427
Mailing address:
  • Phone: 520-349-3296
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1370
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: