=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568135200
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HALIE BROOKE NICHOLS NP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/28/2021
-----------------------------------------------------
Last Update Date | 07/28/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1408 CAMPBELL DR
-----------------------------------------------------
City | IRONTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45638-2301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-533-9719
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 408 5TH AVE
-----------------------------------------------------
City | WORTHINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41183-9421
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-585-1577
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 3016243
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | APRN.CNP.0029222
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | RN.486282
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 1140884
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------