Healthcare Provider Details

I. General information

NPI: 1427559731
Provider Name (Legal Business Name): REGAN ASHLEY NICHOLSON I
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2018
Last Update Date: 02/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 COLLEGE DR.
HATTIESBURG MS
39406
US

IV. Provider business mailing address

23864 HIGHWAY 42
RICHTON MS
39476-2620
US

V. Phone/Fax

Practice location:
  • Phone: 601-266-1000
  • Fax:
Mailing address:
  • Phone: 601-410-7456
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: