Provider Demographics
NPI:1437666294
Name:NICHOLS, JOHN (FNP)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 HEALTH CENTER DR STE 201
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-4693
Mailing Address - Country:US
Mailing Address - Phone:217-238-6055
Mailing Address - Fax:217-258-2216
Practice Address - Street 1:1000 HEALTH CENTER DR
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938
Practice Address - Country:US
Practice Address - Phone:217-238-4325
Practice Address - Fax:217-238-4290
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-02
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209015936208M00000X, 363L00000X, 363LF0000X
MO2017028743363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner