Healthcare Provider Details

I. General information

NPI: 1457745879
Provider Name (Legal Business Name): LUCY CHARLENE NICHOLS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2015
Last Update Date: 03/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12033 AGENCY RD
PARKER AZ
85344-7718
US

IV. Provider business mailing address

12033 AGENCY RD
PARKER AZ
85344-7718
US

V. Phone/Fax

Practice location:
  • Phone: 928-669-2137
  • Fax: 928-669-3131
Mailing address:
  • Phone: 928-669-2137
  • Fax: 928-669-3232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number763170
License Number StateTX

VIII. Authorized Official

Name: LUCY CHARLENE NICHOLS
Title or Position: TRAVEL RN
Credential: RN
Phone: 318-403-1322