Healthcare Provider Details

I. General information

NPI: 1376793463
Provider Name (Legal Business Name): ANGELA ANN NICKELL M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2008
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

819 COLORADO DR
XENIA OH
45385-4859
US

IV. Provider business mailing address

4317 NAPA VALLEY DR
BELLBROOK OH
45305-1567
US

V. Phone/Fax

Practice location:
  • Phone: 937-526-9706
  • Fax:
Mailing address:
  • Phone: 937-562-9706
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number4047407
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number02266
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: