Provider Demographics
NPI:1982581245
Name:NICKELSON, SAMANTHA ASHLEY (DC)
Entity type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:ASHLEY
Last Name:NICKELSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:ASHLEY
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:314 S SHADY SHORES DR STE 100
Mailing Address - Street 2:
Mailing Address - City:LAKE DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75065-3663
Mailing Address - Country:US
Mailing Address - Phone:940-435-1164
Mailing Address - Fax:
Practice Address - Street 1:314 S SHADY SHORES DR STE 100
Practice Address - Street 2:
Practice Address - City:LAKE DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75065-3663
Practice Address - Country:US
Practice Address - Phone:940-435-1164
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-19
Last Update Date:2025-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16578111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor