Healthcare Provider Details

I. General information

NPI: 1992428908
Provider Name (Legal Business Name): LILLIE MAE NICHOLSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2022
Last Update Date: 09/23/2022
Certification Date: 09/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

419 MORGANTOWN ST
KINGWOOD WV
26537-1095
US

IV. Provider business mailing address

419 MORGANTOWN ST
KINGWOOD WV
26537-1095
US

V. Phone/Fax

Practice location:
  • Phone: 304-329-3565
  • Fax:
Mailing address:
  • Phone: 304-329-3565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number19736
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: