Provider Demographics
NPI:1114288453
Name:WEST, NICOLE (PENDING)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:WEST
Suffix:
Gender:F
Credentials:PENDING
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:806 GLENDALE ST
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-4455
Mailing Address - Country:US
Mailing Address - Phone:870-933-9528
Mailing Address - Fax:870-933-9778
Practice Address - Street 1:806 GLENDALE ST
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-4455
Practice Address - Country:US
Practice Address - Phone:870-933-9528
Practice Address - Fax:870-933-9778
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-04
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker