Provider Demographics
NPI:1215626213
Name:NICHOLSON, KENNY L (MSN, APRN, PMHNP-BC)
Entity type:Individual
Prefix:
First Name:KENNY
Middle Name:L
Last Name:NICHOLSON
Suffix:
Gender:M
Credentials:MSN, APRN, PMHNP-BC
Other - Prefix:
Other - First Name:KEN
Other - Middle Name:L
Other - Last Name:NICHOLSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSN, APRN, PMHNP-BC
Mailing Address - Street 1:113 SHADOWOOD CT
Mailing Address - Street 2:
Mailing Address - City:SENECA
Mailing Address - State:SC
Mailing Address - Zip Code:29678-1275
Mailing Address - Country:US
Mailing Address - Phone:864-985-3915
Mailing Address - Fax:
Practice Address - Street 1:125 MUDDY TOES DR
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29626-5349
Practice Address - Country:US
Practice Address - Phone:864-353-3384
Practice Address - Fax:864-222-9715
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-04
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC27318363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health