Provider Demographics
NPI:1427864222
Name:NICKSON, TICA NICOLE (CPD, CLC, CCHW)
Entity type:Individual
Prefix:MRS
First Name:TICA
Middle Name:NICOLE
Last Name:NICKSON
Suffix:
Gender:F
Credentials:CPD, CLC, CCHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 EAST AVE STE 106
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16503-1535
Mailing Address - Country:US
Mailing Address - Phone:814-449-6200
Mailing Address - Fax:
Practice Address - Street 1:650 EAST AVE STE 106
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16503-1535
Practice Address - Country:US
Practice Address - Phone:814-449-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-06
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA21072172V00000X, 374J00000X
PA174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
No172V00000XOther Service ProvidersCommunity Health Worker
No174N00000XOther Service ProvidersLactation Consultant, Non-RN