Provider Demographics
NPI:1861636896
Name:NICHOLS, JOHNNETTA MATRICE
Entity type:Individual
Prefix:MS
First Name:JOHNNETTA
Middle Name:MATRICE
Last Name:NICHOLS
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 1:8209 N. MAIN ST.
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77022
Mailing Address - Country:US
Mailing Address - Phone:713-692-1414
Mailing Address - Fax:713-692-2157
Practice Address - Street 1:8209 N. MAIN ST.
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77022
Practice Address - Country:US
Practice Address - Phone:713-692-1414
Practice Address - Fax:713-692-2157
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-21
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
310400000X
TX102737310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXF500193420Medicaid
TX1861636896Medicaid
TX205828380Medicaid