MEDICARE: BEVERLY NICHOLS

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	364SH0200X	Home Health Clinical Nurse Specialist	9569L001	NY
2	374U00000X	Home Health Aide	9569L001	NY
3	174400000X	Specialist	9569L001	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1255403242
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BEVERLY NICHOLS

Provider Business Mailing Address
First Line	:	12510 QUEENS BLVD
Second Line	:
City	:	KEW GARDENS
State	:	NY
Zip	:	11415-1519
Country	:	US
Telephone Number	:	718-459-5592
Fax Number	:	718-459-6047

Provider Business Practice Location Address
First Line	:	12510 QUEENS BLVD
Second Line	:
City	:	KEW GARDENS
State	:	NY
Zip	:	11415-1519
Country	:	US
Telephone Number	:	718-459-5592
Fax Number	:	718-459-6047

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

Provider Enumeration Date	:	11/14/2006
Last Update Date	:	12/13/2021

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Directions to “ BEVERLY NICHOLS ” Practice Location

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