Healthcare Provider Details

I. General information

NPI: 1609082486
Provider Name (Legal Business Name): NICOLE DENISE NICKENS MSN, A-GPNP-BC,
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE DENISE NICKENS MSN, A-GPNP-BC,

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 03/11/2026
Certification Date: 03/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12395 MCCRACKEN RD
GARFIELD HTS OH
44125-2967
US

IV. Provider business mailing address

12395 MCCRACKEN RD
GARFIELD HTS OH
44125-2967
US

V. Phone/Fax

Practice location:
  • Phone: 216-587-6727
  • Fax:
Mailing address:
  • Phone: 216-587-6727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License NumberCNP020745
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN.CNP.020745
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN346914
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: