Healthcare Provider Details

I. General information

NPI: 1326636978
Provider Name (Legal Business Name): KELSEY ANNE NICHOLES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2021
Last Update Date: 01/08/2021
Certification Date: 01/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL PARK
WHEELING WV
26003-6300
US

IV. Provider business mailing address

6 LAURELWOOD ST
WHEELING WV
26003-9717
US

V. Phone/Fax

Practice location:
  • Phone: 304-243-2980
  • Fax:
Mailing address:
  • Phone: 740-296-4542
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License Number107722
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: