Provider Demographics
NPI:1992471825
Name:ROYSTER, NICKIE ANN
Entity type:Individual
Prefix:
First Name:NICKIE
Middle Name:ANN
Last Name:ROYSTER
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 1:115 PRIVATE ROAD 977
Mailing Address - Street 2:
Mailing Address - City:PEDRO
Mailing Address - State:OH
Mailing Address - Zip Code:45659-8608
Mailing Address - Country:US
Mailing Address - Phone:740-534-1386
Mailing Address - Fax:740-534-1497
Practice Address - Street 1:115 PRIVATE ROAD 977
Practice Address - Street 2:
Practice Address - City:PEDRO
Practice Address - State:OH
Practice Address - Zip Code:45659-8608
Practice Address - Country:US
Practice Address - Phone:740-534-1386
Practice Address - Fax:740-534-1497
Is Sole Proprietor?:No
Enumeration Date:2021-08-19
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.158930.MEDS-IV164W00000X
171M00000X
OHRN.532989163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse
No171M00000XOther Service ProvidersCase Manager/Care Coordinator