Provider Demographics
NPI:1750607826
Name:NICHOLSON, KELLY
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:STICKELMEYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:101 W CATALDO AVE STE 301
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99201-3202
Mailing Address - Country:US
Mailing Address - Phone:509-327-1994
Mailing Address - Fax:509-327-1911
Practice Address - Street 1:101 W CATALDO AVE STE 301
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201-3202
Practice Address - Country:US
Practice Address - Phone:509-327-1994
Practice Address - Fax:509-327-1911
Is Sole Proprietor?:No
Enumeration Date:2010-04-14
Last Update Date:2011-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60111547225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA 60111547OtherWASHINGTON STATE DEPARTMENT OF HEALTH