Healthcare Provider Details

I. General information

NPI: 1336630805
Provider Name (Legal Business Name): YANINA GLENDA NIKOLAUS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2018
Last Update Date: 07/12/2023
Certification Date: 07/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 1ST AVE
HUNTINGTON WV
25702-1241
US

IV. Provider business mailing address

1448 10TH AVE STE 304
HUNTINGTON WV
25701-3579
US

V. Phone/Fax

Practice location:
  • Phone: 304-691-8850
  • Fax:
Mailing address:
  • Phone: 304-691-8850
  • Fax: 304-523-9470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License Number32375
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number32375
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: