MEDICARE: MS. NICOLE DENISE NICKENS MSN, A-GPNP-BC,

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	163W00000X	Registered Nurse	RN346914	OH
2	207RA0401X	Addiction Medicine (Internal Medicine) Physician	CNP020745	OH
3	363L00000X	Nurse Practitioner	APRN.CNP.020745	OH

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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1609082486
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. NICOLE DENISE NICKENS MSN, A-GPNP-BC,

Provider Business Mailing Address
First Line	:	30841 EUCLID AVE STE 103
Second Line	:
City	:	WILLOUGHBY
State	:	OH
Zip	:	44094-3100
Country	:	US
Telephone Number	:	216-441-2496
Fax Number	:	216-453-5966

Provider Business Practice Location Address
First Line	:	30841 EUCLID AVE STE 103
Second Line	:
City	:	WILLOUGHBY
State	:	OH
Zip	:	44094-3100
Country	:	US
Telephone Number	:	216-441-2496
Fax Number	:	216-453-5966

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

Provider Enumeration Date	:	05/16/2007
Last Update Date	:	06/23/2025

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