MEDICARE: KAMERON RYLIE NICHOLSON

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	3747P1801X	Personal Care Attendant

General Provider Information

NPI Number	:	1912656976
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAMERON RYLIE NICHOLSON

Provider Business Mailing Address
First Line	:	266 S RIVER AVE
Second Line	:
City	:	WESTON
State	:	WV
Zip	:	26452-1534
Country	:	US
Telephone Number	:	681-533-3098
Fax Number	:

Provider Business Practice Location Address
First Line	:	266 S RIVER AVE
Second Line	:
City	:	WESTON
State	:	WV
Zip	:	26452-1534
Country	:	US
Telephone Number	:	681-533-3098
Fax Number	:

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

Provider Enumeration Date	:	03/18/2022
Last Update Date	:	03/18/2022

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