Provider Demographics
NPI:1053791293
Name:NICHOLAS, CARLY ELIZABETH (CNP)
Entity type:Individual
Prefix:MRS
First Name:CARLY
Middle Name:ELIZABETH
Last Name:NICHOLAS
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:MS
Other - First Name:CARLY
Other - Middle Name:ELIZABETH
Other - Last Name:GARMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7545 BEECHMONT AVE STE N
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45255-4231
Mailing Address - Country:US
Mailing Address - Phone:513-232-0011
Mailing Address - Fax:513-232-8434
Practice Address - Street 1:7545 BEECHMONT AVE STE N
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45255-4231
Practice Address - Country:US
Practice Address - Phone:513-232-0011
Practice Address - Fax:513-232-8434
Is Sole Proprietor?:No
Enumeration Date:2015-06-03
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP17660363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0138769Medicaid