Provider Demographics
NPI:1104056878
Name:NICHOLAS, JANE ELIZABETH (MD)
Entity type:Individual
Prefix:
First Name:JANE
Middle Name:ELIZABETH
Last Name:NICHOLAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:97 GREAT TEAYS BLVD
Mailing Address - Street 2:STE 6
Mailing Address - City:SCOTT DEPOT
Mailing Address - State:WV
Mailing Address - Zip Code:25560-9816
Mailing Address - Country:US
Mailing Address - Phone:304-757-6999
Mailing Address - Fax:304-201-5019
Practice Address - Street 1:800 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25302-3351
Practice Address - Country:US
Practice Address - Phone:304-414-1880
Practice Address - Fax:304-414-1886
Is Sole Proprietor?:No
Enumeration Date:2009-07-16
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WV20979208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3003934000Medicaid
WVWV1420B59Medicare PIN
WVH80736Medicare UPIN
WV7310761Medicare PIN