Provider Demographics
NPI:1588933592
Name:NICHOLS, DAVID E
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:E
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 1:3333 CHANATE RD
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-1707
Mailing Address - Country:US
Mailing Address - Phone:707-565-7829
Mailing Address - Fax:
Practice Address - Street 1:3333 CHANATE RD
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-1707
Practice Address - Country:US
Practice Address - Phone:707-565-7829
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-20
Last Update Date:2016-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN795142163W00000X
CA95004102363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse