Basic Information
Provider Information
NPI: 1033557764
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: NICKOLSON
FirstName: CHELSEA
MiddleName: ANN
NamePrefix: DR.
NameSuffix:  
Credential: D.O., M.B.A.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 405 W GRAND AVE
Address2:  
City: DAYTON
State: OH
PostalCode: 454054720
CountryCode: US
TelephoneNumber: 9377233248
FaxNumber:  
Practice Location
Address1: 405 W GRAND AVE
Address2:  
City: DAYTON
State: OH
PostalCode: 454054720
CountryCode: US
TelephoneNumber: 9377233248
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/04/2013
LastUpdateDate: 06/16/2016
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207R00000X34.011828OHY Allopathic & Osteopathic PhysiciansInternal Medicine 
390200000X  N Student, Health CareStudent in an Organized Health Care Education/Training Program 

ID Information
IDTypeStateIssuerDescription
34.01182801OHLICENSEOTHER


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