Provider Demographics
NPI:1598874760
Name:NICHOLSON, TONIA MARIE (CRNA)
Entity Type:Individual
Prefix:
First Name:TONIA
Middle Name:MARIE
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 E 17TH ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6313
Mailing Address - Country:US
Mailing Address - Phone:208-525-2090
Mailing Address - Fax:208-525-2662
Practice Address - Street 1:3071 E FRANKLIN RD
Practice Address - Street 2:STE 101
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-2376
Practice Address - Country:US
Practice Address - Phone:208-288-1400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDN-21540367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1602306Medicare ID - Type Unspecified