Provider Demographics
NPI:1417220252
Name:NICHOLSON, ELIZABETH LEE (CRNA)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:LEE
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1428 CLIFTON WAY CT
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-7394
Mailing Address - Country:US
Mailing Address - Phone:618-977-3784
Mailing Address - Fax:
Practice Address - Street 1:3636 N BELT W
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-5947
Practice Address - Country:US
Practice Address - Phone:618-233-5050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-09
Last Update Date:2016-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.009368367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered