Healthcare Provider Details

I. General information

NPI: 1336197078
Provider Name (Legal Business Name): KATRINA NICKELS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATRINA SANDOVAL

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 08/08/2022
Certification Date: 08/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 ROSE ST
LEXINGTON KY
40536-3229
US

IV. Provider business mailing address

2312 ALEXANDRIA DR
LEXINGTON KY
40504-3229
US

V. Phone/Fax

Practice location:
  • Phone: 859-257-1000
  • Fax: 859-257-1342
Mailing address:
  • Phone: 859-276-5344
  • Fax: 859-296-0362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number39009
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number39009
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number39009
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: