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NPI Code Detail

MEDICARE: KRISTYN JOY NICHOLS MSW

MEDICARE: KRISTYN JOY NICHOLS MSW
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
1104100000XSocial Worker

General Provider Information

NPI Number : 1396481974
Entity Type Code : Individual
Provider Name (Legal Business Name) : KRISTYN JOY NICHOLS MSW
Provider Business Mailing Address
First Line : 1698 FORT JESSE RD APT 2
Second Line :
City : NORMAL
State : IL
Zip : 61761-6236
Country : US
Telephone Number : 618-704-8454
Fax Number :
Provider Business Practice Location Address
First Line : 2206 EASTLAND DR STE 101
Second Line :
City : BLOOMINGTON
State : IL
Zip : 61704-7742
Country : US
Telephone Number : 217-714-7042
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/07/2022
Last Update Date : 01/06/2023

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