MEDICARE: SALLY A. 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	171M00000X	Case Manager/Care Coordinator

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	:	1710323746
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SALLY A. NICHOLS

Provider Business Mailing Address
First Line	:	100 W GRIGGS AVE
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88001-1234
Country	:	US
Telephone Number	:	575-647-2800
Fax Number	:	575-647-2898

Provider Business Practice Location Address
First Line	:	2211 N. VALLEY DR
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88001
Country	:	US
Telephone Number	:	575-527-7911
Fax Number	:	575-527-4287

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

Provider Enumeration Date	:	05/16/2013
Last Update Date	:	02/20/2015

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Directions to “ SALLY A. NICHOLS ” Practice Location

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