Basic Information
| Provider Information | |||||||||
| NPI: | 1780085480 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NICHOLS | ||||||||
| FirstName: | REGINALD | ||||||||
| MiddleName: | SCOTT | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 116 JUNCO LN | ||||||||
| Address2: | |||||||||
| City: | BREVARD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287129824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8285569134 | ||||||||
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| Practice Location | |||||||||
| Address1: | 571 S ALLEN RD | ||||||||
| Address2: | |||||||||
| City: | FLAT ROCK | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28731 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8286926178 | ||||||||
| FaxNumber: | 8283563996 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2014 | ||||||||
| LastUpdateDate: | 09/21/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 5007158 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 5007158 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 5007158 | 01 | NC | NURSE PRACTITIONER | OTHER | 1780085480 | 05 | NC | MEDICAID | 247416 | 01 | NC | RN | OTHER | MN3301203 | 01 | NC | DEA | OTHER |