Provider Demographics
NPI:1275546020
Name:NICHOLSON, SUSAN KAY (PA)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:KAY
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:SUSAN
Other - Middle Name:KAY
Other - Last Name:SMITLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:915 N GRAND BLVD
Mailing Address - Street 2:111-JC/GI
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63106-1621
Mailing Address - Country:US
Mailing Address - Phone:314-652-4100
Mailing Address - Fax:314-289-7035
Practice Address - Street 1:915 N GRAND BLVD
Practice Address - Street 2:111-JC/GI
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63106-1621
Practice Address - Country:US
Practice Address - Phone:314-652-4100
Practice Address - Fax:314-289-7035
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant