Provider Demographics
NPI:1487031159
Name:NICHOLS, JENNIFER (APRN)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 727
Mailing Address - Street 2:
Mailing Address - City:ALVA
Mailing Address - State:OK
Mailing Address - Zip Code:73717-0727
Mailing Address - Country:US
Mailing Address - Phone:580-430-3333
Mailing Address - Fax:580-430-3375
Practice Address - Street 1:410 4TH ST STE J
Practice Address - Street 2:
Practice Address - City:ALVA
Practice Address - State:OK
Practice Address - Zip Code:73717-2363
Practice Address - Country:US
Practice Address - Phone:580-430-3333
Practice Address - Fax:580-430-3375
Is Sole Proprietor?:No
Enumeration Date:2015-05-01
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK90378163W00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200589510AMedicaid
OK200589510AMedicaid