Provider Demographics
NPI:1407809189
Name:NICHOLS, CARRIE J (MD)
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:J
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 MERCY CIRCLE
Mailing Address - Street 2:FAMILY MEDICINE DEPT
Mailing Address - City:CAMP PENDLETON
Mailing Address - State:CA
Mailing Address - Zip Code:92058
Mailing Address - Country:US
Mailing Address - Phone:760-719-3616
Mailing Address - Fax:760-725-1101
Practice Address - Street 1:200 MERCY CIRCLE
Practice Address - Street 2:FAMILY MEDICINE DEPT
Practice Address - City:CAMP PENDLETON
Practice Address - State:CA
Practice Address - Zip Code:92058
Practice Address - Country:US
Practice Address - Phone:760-719-3616
Practice Address - Fax:760-725-1101
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2025-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA83442207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA83442OtherMEDICAL LICENSE
CA00A834420Medicaid
CA00A834420Medicaid