Healthcare Provider Details

I. General information

NPI: 1134049505
Provider Name (Legal Business Name): LUCILLE NICHOLSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2026
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 GLENWOOD AVE STE 200
RALEIGH NC
27612-3857
US

IV. Provider business mailing address

1704 CRAG BURN LN
RALEIGH NC
27604-6900
US

V. Phone/Fax

Practice location:
  • Phone: 984-302-1452
  • Fax:
Mailing address:
  • Phone: 984-302-1452
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: