Provider Demographics
NPI:1407288608
Name:NICKLSON, CHRISTINA L (RN)
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:L
Last Name:NICKLSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1510 BYRUM RD
Mailing Address - Street 2:
Mailing Address - City:BLYTHEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72315-8033
Mailing Address - Country:US
Mailing Address - Phone:870-532-2600
Mailing Address - Fax:
Practice Address - Street 1:1510 BYRUM RD
Practice Address - Street 2:
Practice Address - City:BLYTHEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72315-8033
Practice Address - Country:US
Practice Address - Phone:870-532-2600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-30
Last Update Date:2013-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012004417163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse