Basic Information
Provider Information
NPI: 1003003682
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: NICHOLSON
FirstName: LAURIE
MiddleName: F
NamePrefix:  
NameSuffix:  
Credential: O.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName: NICHOLSON WEXLER
OtherFirstName: LAURIE
OtherMiddleName: F
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType: 5
Mailing Information
Address1: 6010 S HOLLY ST
Address2:  
City: GREENWOOD VILLAGE
State: CO
PostalCode: 801114251
CountryCode: US
TelephoneNumber: 3037219666
FaxNumber:  
Practice Location
Address1: 6010 S HOLLY ST
Address2:  
City: GREENWOOD VILLAGE
State: CO
PostalCode: 801114251
CountryCode: US
TelephoneNumber: 3037219666
FaxNumber:  
Other Information
ProviderEnumerationDate: 09/27/2007
LastUpdateDate: 09/27/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
152W00000X1486COY Eye and Vision Services ProvidersOptometrist 

No ID Information.


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