Basic Information
| Provider Information | |||||||||
| NPI: | 1255403242 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NICHOLS | ||||||||
| FirstName: | BEVERLY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12510 QUEENS BLVD | ||||||||
| Address2: | |||||||||
| City: | KEW GARDENS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114151519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184595592 | ||||||||
| FaxNumber: | 7184596047 | ||||||||
| Practice Location | |||||||||
| Address1: | 12510 QUEENS BLVD | ||||||||
| Address2: | |||||||||
| City: | KEW GARDENS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114151519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184595592 | ||||||||
| FaxNumber: | 7184596047 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2006 | ||||||||
| LastUpdateDate: | 12/13/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SH0200X | 9569L001 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Home Health | 374U00000X | 9569L001 | NY | N | Nursing Service Related Providers | Home Health Aide | 174400000X | 9569L001 | NY | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 01761260 | 05 | NY | MEDICAID |