MEDICARE: ELLEN AUDRA NICOLA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	1988	NC

General Provider Information

NPI Number	:	1154354058
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELLEN AUDRA NICOLA

Provider Business Mailing Address
First Line	:	100 KIMEL FOREST DR.
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27103-6074
Country	:	US
Telephone Number	:	336-716-1331
Fax Number	:

Provider Business Practice Location Address
First Line	:	1208 EASTCHESTER DR
Second Line	:	SUITE 200
City	:	HIGH POINT
State	:	NC
Zip	:	27265-3170
Country	:	US
Telephone Number	:	336-802-2536
Fax Number	:	336-802-2534

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/07/2006
Last Update Date	:	10/25/2024

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