Basic Information
| Provider Information | |||||||||
| NPI: | 1154341741 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NICHOLS | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WEATHERBY | ||||||||
| OtherFirstName: | AMANDA | ||||||||
| OtherMiddleName: | E | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 30575 BAINBRIDGE RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | SOLON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441392275 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4403686868 | ||||||||
| FaxNumber: | 4403686866 | ||||||||
| Practice Location | |||||||||
| Address1: | 30575 BAINBRIDGE RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | SOLON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441392275 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4403686868 | ||||||||
| FaxNumber: | 4403686866 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 01/11/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 08915 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | RN293365 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 200831990 | 05 | IN | MEDICAID | 78017902 | 05 | KY | MEDICAID | 2679463 | 05 | OH | MEDICAID |