MEDICARE: NICHOLE SPJUT

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	171M00000X	Case Manager/Care Coordinator
2	1041C0700X	Clinical Social Worker	255497	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00000	OTHER		LICENSURE

General Provider Information

NPI Number	:	1568977411
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICHOLE SPJUT

Provider Business Mailing Address
First Line	:	305 ARTILLERY PARK DR UNIT 102
Second Line	:
City	:	FORT MITCHELL
State	:	KY
Zip	:	41017-2794
Country	:	US
Telephone Number	:	859-429-2120
Fax Number	:

Provider Business Practice Location Address
First Line	:	305 ARTILLERY PARK DR UNIT 102
Second Line	:
City	:	FORT MITCHELL
State	:	KY
Zip	:	41017-2794
Country	:	US
Telephone Number	:	859-429-2120
Fax Number	:

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

Provider Enumeration Date	:	12/13/2017
Last Update Date	:	04/08/2021

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Directions to “ NICHOLE SPJUT ” Practice Location

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