Provider Demographics
NPI:1487624607
Name:NICHOLS-BYLL, STACY ANN (MD)
Entity type:Individual
Prefix:DR
First Name:STACY
Middle Name:ANN
Last Name:NICHOLS-BYLL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:STACY
Other - Middle Name:ANN
Other - Last Name:NICHOLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1119 ROAD L
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:NE
Mailing Address - Zip Code:68361-3103
Mailing Address - Country:US
Mailing Address - Phone:830-399-5455
Mailing Address - Fax:
Practice Address - Street 1:302 W PHILLIP AVE
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:NE
Practice Address - Zip Code:68701-5248
Practice Address - Country:US
Practice Address - Phone:402-371-8000
Practice Address - Fax:402-371-0971
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-34598208000000X
VA0101245035208000000X
FLME111597208000000X
NE21188208000000X
IN01049920A208000000X
AL18698208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
G51977Medicare UPIN