Healthcare Provider Details

I. General information

NPI: 1427864222
Provider Name (Legal Business Name): TICA NICOLE NICKSON CPD, CLC, CCHW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2024
Last Update Date: 12/06/2024
Certification Date: 12/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 EAST AVE STE 106
ERIE PA
16503-1535
US

IV. Provider business mailing address

650 EAST AVE STE 106
ERIE PA
16503-1535
US

V. Phone/Fax

Practice location:
  • Phone: 814-449-6200
  • Fax:
Mailing address:
  • Phone: 814-449-6200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number21072
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code374J00000X
TaxonomyDoula
License Number21072
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: