Provider Demographics
NPI:1568079176
Name:NICHOLS, CONNER
Entity type:Individual
Prefix:
First Name:CONNER
Middle Name:
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 189
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73402-0189
Mailing Address - Country:US
Mailing Address - Phone:580-319-7305
Mailing Address - Fax:580-319-7328
Practice Address - Street 1:2010 BOREN BLVD
Practice Address - Street 2:
Practice Address - City:SEMINOLE
Practice Address - State:OK
Practice Address - Zip Code:74868-2050
Practice Address - Country:US
Practice Address - Phone:053-824-5074
Practice Address - Fax:405-382-5269
Is Sole Proprietor?:No
Enumeration Date:2020-09-28
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator