Healthcare Provider Details

I. General information

NPI: 1518620061
Provider Name (Legal Business Name): ANGELA LYNN NICHOLSON LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ANGELA LYNN KARING LMT

II. Dates (important events)

Enumeration Date: 10/20/2021
Last Update Date: 10/20/2021
Certification Date: 10/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5273 CADWALLADER SONK RD
FOWLER OH
44418-9735
US

IV. Provider business mailing address

PO BOX 84
FOWLER OH
44418-0084
US

V. Phone/Fax

Practice location:
  • Phone: 724-718-8389
  • Fax:
Mailing address:
  • Phone: 724-718-8389
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number33.012112
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: