Provider Demographics
NPI:1417284662
Name:NICHOLS, MARLA (CRNA)
Entity Type:Individual
Prefix:
First Name:MARLA
Middle Name:
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:MARLA
Other - Middle Name:
Other - Last Name:UPCHURCH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 505164
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-5164
Mailing Address - Country:US
Mailing Address - Phone:855-420-7900
Mailing Address - Fax:
Practice Address - Street 1:1235 E CHEROKEE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2203
Practice Address - Country:US
Practice Address - Phone:417-820-2829
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO127574367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKPENDINGMedicaid
MOPENDINGOtherMEDICARE
MOPENDINGMedicaid
ARPENDINGMedicaid