Provider Demographics
NPI:1316305782
Name:NICKEL, TINA MARIE (LPN)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:NICKEL
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:617 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:PORT CLINTON
Mailing Address - State:OH
Mailing Address - Zip Code:43452-1109
Mailing Address - Country:US
Mailing Address - Phone:567-201-0654
Mailing Address - Fax:
Practice Address - Street 1:617 E 3RD ST
Practice Address - Street 2:
Practice Address - City:PORT CLINTON
Practice Address - State:OH
Practice Address - Zip Code:43452-1109
Practice Address - Country:US
Practice Address - Phone:567-201-0654
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-01
Last Update Date:2016-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.119484-M-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse