Healthcare Provider Details

I. General information

NPI: 1386256717
Provider Name (Legal Business Name): HEATHER NICOLE NICKELL FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HEATHER NICOLE FABIAN

II. Dates (important events)

Enumeration Date: 08/18/2020
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 RICHLAND MALL
ONTARIO OH
44906-1246
US

IV. Provider business mailing address

700 N COLUMBUS ST
CRESTLINE OH
44827-1455
US

V. Phone/Fax

Practice location:
  • Phone: 419-562-3470
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0027224
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: