Healthcare Provider Details

I. General information

NPI: 1366221764
Provider Name (Legal Business Name): KIANDRE NICHOLS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2023
Last Update Date: 11/15/2023
Certification Date: 11/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 S BROAD ST STE 7
NEW ORLEANS LA
70119-6447
US

IV. Provider business mailing address

200 S BROAD ST STE 7
NEW ORLEANS LA
70119-6447
US

V. Phone/Fax

Practice location:
  • Phone: 504-209-1214
  • Fax:
Mailing address:
  • Phone: 504-209-1214
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: