Healthcare Provider Details

I. General information

NPI: 1982581245
Provider Name (Legal Business Name): SAMANTHA ASHLEY NICKELSON DC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SAMANTHA ASHLEY MILLER

II. Dates (important events)

Enumeration Date: 08/19/2025
Last Update Date: 08/19/2025
Certification Date: 08/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 S SHADY SHORES DR STE 100
LAKE DALLAS TX
75065-3663
US

IV. Provider business mailing address

314 S SHADY SHORES DR STE 100
LAKE DALLAS TX
75065-3663
US

V. Phone/Fax

Practice location:
  • Phone: 940-435-1164
  • Fax:
Mailing address:
  • Phone: 940-435-1164
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number16578
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: