Healthcare Provider Details

I. General information

NPI: 1457196255
Provider Name (Legal Business Name): ANGELIA BROOKE NICHOLS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2024
Last Update Date: 06/25/2024
Certification Date: 06/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 W NORTH ST
LIMA OH
45801-4217
US

IV. Provider business mailing address

630 W NORTH ST
LIMA OH
45801-4217
US

V. Phone/Fax

Practice location:
  • Phone: 419-496-8700
  • Fax:
Mailing address:
  • Phone: 419-496-8700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: