Provider Demographics
NPI:1891100624
Name:DRAGON, NICHELLE
Entity type:Individual
Prefix:
First Name:NICHELLE
Middle Name:
Last Name:DRAGON
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 1:1245 HANKINS RD NE APT 2
Mailing Address - Street 2:
Mailing Address - City:MASSILLON
Mailing Address - State:OH
Mailing Address - Zip Code:44646-4483
Mailing Address - Country:US
Mailing Address - Phone:330-575-8919
Mailing Address - Fax:
Practice Address - Street 1:1245 HANKINS RD NE APT 2
Practice Address - Street 2:
Practice Address - City:MASSILLON
Practice Address - State:OH
Practice Address - Zip Code:44646-4483
Practice Address - Country:US
Practice Address - Phone:330-575-8919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-01
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3073669374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3073669Medicaid