Healthcare Provider Details

I. General information

NPI: 1659881530
Provider Name (Legal Business Name): KELLY NICHOLS APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 E DELAWARE AVE
NEWARK DE
19711-4605
US

IV. Provider business mailing address

625 N SHIPLEY ST
WILMINGTON DE
19801-2228
US

V. Phone/Fax

Practice location:
  • Phone: 302-731-7801
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberLH-0000226
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: