Healthcare Provider Details

I. General information

NPI: 1831008564
Provider Name (Legal Business Name): ZANIYAH ANN NICKERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

1300 EAGLE RD
ST DAVIDS PA
19087-3617
US

IV. Provider business mailing address

813 E HAINES ST
PHILADELPHIA PA
19138-1729
US

V. Phone/Fax

Practice location:
  • Phone: 610-341-5800
  • Fax:
Mailing address:
  • Phone: 267-324-1400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: