Provider Demographics
NPI:1437304839
Name:NETTLES, NICHOLAS EDMUND SR
Entity Type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:EDMUND
Last Name:NETTLES
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 LUCY LN
Mailing Address - Street 2:
Mailing Address - City:SHERWOOD
Mailing Address - State:AR
Mailing Address - Zip Code:72120-3612
Mailing Address - Country:US
Mailing Address - Phone:501-834-3652
Mailing Address - Fax:
Practice Address - Street 1:4400 SHUFFIELD DR
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-7100
Practice Address - Country:US
Practice Address - Phone:501-686-9300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-26
Last Update Date:2008-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator