Provider Demographics
NPI:1497189856
Name:OWENS, NICHOLE ANDERSON (FNP-C)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:ANDERSON
Last Name:OWENS
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:NICHOLE
Other - Middle Name:MARIE
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-C
Mailing Address - Street 1:2500 N STATE ST
Mailing Address - Street 2:UMMC - DEPARTMENT OF SURGERY
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:UMMC - DEPARTMENT OF SURGERY
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-815-2005
Practice Address - Fax:601-984-6451
Is Sole Proprietor?:No
Enumeration Date:2013-08-21
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR877296363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02459205Medicaid
MSP01402442OtherRR MEDICARE
MSP01402442OtherRR MEDICARE