Provider Demographics
NPI:1508802208
Name:NICKELS, COURTNEY GIBSON (NP)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:GIBSON
Last Name:NICKELS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:ANNE
Other - Last Name:GIBSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1164 MELROSE ST
Mailing Address - Street 2:
Mailing Address - City:STARKVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39759-9055
Mailing Address - Country:US
Mailing Address - Phone:601-503-6912
Mailing Address - Fax:662-320-7797
Practice Address - Street 1:1207 HIGHWAY 182 W
Practice Address - Street 2:
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759-9820
Practice Address - Country:US
Practice Address - Phone:662-320-7800
Practice Address - Fax:662-320-7797
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2010-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR865275363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily