Provider Demographics
NPI:1235645151
Name:NICHOLS, COURTNEY R (NP-C)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:R
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1239
Mailing Address - Street 2:
Mailing Address - City:HANNIBAL
Mailing Address - State:MO
Mailing Address - Zip Code:63401-1239
Mailing Address - Country:US
Mailing Address - Phone:660-665-7575
Mailing Address - Fax:660-665-7576
Practice Address - Street 1:1611 S BALTIMORE ST STE A
Practice Address - Street 2:
Practice Address - City:KIRKSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63501-4519
Practice Address - Country:US
Practice Address - Phone:660-665-7575
Practice Address - Fax:660-665-7576
Is Sole Proprietor?:No
Enumeration Date:2017-12-15
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007025283163W00000X
MO2017042162363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse