Basic Information
| Provider Information | |||||||||
| NPI: | 1558327817 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NICHOLS | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | K. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OD, MPH, PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1716 UNIVERSITY BLVD | ||||||||
| Address2: | HPB G080A | ||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352940010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2059752020 | ||||||||
| FaxNumber: | 2059346755 | ||||||||
| Practice Location | |||||||||
| Address1: | 1716 UNIVERSITY BLVD | ||||||||
| Address2: | HPB G080A | ||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352940010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2059752020 | ||||||||
| FaxNumber: | 2059346755 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2006 | ||||||||
| LastUpdateDate: | 07/24/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | T-215-TA-976 | AL | N | Eye and Vision Services Providers | Optometrist | 152WC0802X | 4722/T1517 | OH | N | Eye and Vision Services Providers | Optometrist | Corneal and Contact Management | 152WC0802X | 7914TG | TX | N | Eye and Vision Services Providers | Optometrist | Corneal and Contact Management | 152W00000X | R-222-TA-976 | AL | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 112409104 | 05 | TX | MEDICAID |