Provider Demographics
NPI:1447915475
Name:NICELY, JODIE MAE
Entity type:Individual
Prefix:
First Name:JODIE
Middle Name:MAE
Last Name:NICELY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1212 MARCUM TER
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25705-1424
Mailing Address - Country:US
Mailing Address - Phone:304-704-5303
Mailing Address - Fax:
Practice Address - Street 1:1212 MARCUM TER
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25705-1424
Practice Address - Country:US
Practice Address - Phone:304-704-5303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-04
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant