Healthcare Provider Details

I. General information

NPI: 1427978303
Provider Name (Legal Business Name): AUTUMN NICKELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2026
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 W SYCAMORE ST
COLUMBUS OH
43215-5618
US

IV. Provider business mailing address

379 LEBANON ST
MONROE OH
45050-1408
US

V. Phone/Fax

Practice location:
  • Phone: 614-340-7980
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number03446998
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: