Provider Demographics
NPI:1669187035
Name:NICHOLS, KELLY (MSLAC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:MSLAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 S PERRY ST STE 100
Mailing Address - Street 2:
Mailing Address - City:CASTLE ROCK
Mailing Address - State:CO
Mailing Address - Zip Code:80104-3376
Mailing Address - Country:US
Mailing Address - Phone:720-340-7500
Mailing Address - Fax:
Practice Address - Street 1:815 S PERRY ST STE 100
Practice Address - Street 2:
Practice Address - City:CASTLE ROCK
Practice Address - State:CO
Practice Address - Zip Code:80104-3376
Practice Address - Country:US
Practice Address - Phone:720-340-7500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-19
Last Update Date:2025-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0002050171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty