Healthcare Provider Details

I. General information

NPI: 1659002970
Provider Name (Legal Business Name): NICHOLAS NIEMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2022
Last Update Date: 06/17/2022
Certification Date: 06/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

773 MAXOLA AVE
NEWARK OH
43055-2845
US

IV. Provider business mailing address

773 MAXOLA AVE
NEWARK OH
43055-2845
US

V. Phone/Fax

Practice location:
  • Phone: 740-334-7403
  • Fax:
Mailing address:
  • Phone: 740-334-7403
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License NumberRN.396570
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: