Provider Demographics
NPI:1306550249
Name:NICKELL, STEPHANIE RENEE
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:RENEE
Last Name:NICKELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 ELLINGTON TER
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040-5147
Mailing Address - Country:US
Mailing Address - Phone:931-220-3116
Mailing Address - Fax:
Practice Address - Street 1:300 SANGO DR
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-6822
Practice Address - Country:US
Practice Address - Phone:931-368-9622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-05
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000134310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility