Provider Demographics
NPI:1699077792
Name:NICHOLS, KERRI
Entity type:Individual
Prefix:
First Name:KERRI
Middle Name:
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 JOE LICK RD
Mailing Address - Street 2:
Mailing Address - City:SCOTT TWP
Mailing Address - State:PA
Mailing Address - Zip Code:18447-7626
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:119 JOE LICK RD
Practice Address - Street 2:
Practice Address - City:SCOTT TWP
Practice Address - State:PA
Practice Address - Zip Code:18447-7626
Practice Address - Country:US
Practice Address - Phone:570-563-2759
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-22
Last Update Date:2010-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOP003158L224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant