Basic Information
| Provider Information | |||||||||
| NPI: | 1518638519 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NICHOLS | ||||||||
| FirstName: | KRYSTINE | ||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NICHOLS | ||||||||
| OtherFirstName: | KRYSTINE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 202 PINE ST | ||||||||
| Address2: | |||||||||
| City: | CHESANING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486161252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9893232090 | ||||||||
| FaxNumber: | 9893233991 | ||||||||
| Practice Location | |||||||||
| Address1: | 202 PINE ST | ||||||||
| Address2: | |||||||||
| City: | CHESANING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486161252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9893232090 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2021 | ||||||||
| LastUpdateDate: | 02/14/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | Y |
No ID Information.