Provider Demographics
NPI:1609316694
Name:SUZANNE NICHOLAS LLC
Entity Type:Organization
Organization Name:SUZANNE NICHOLAS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:NICHOLAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-538-9601
Mailing Address - Street 1:2224 RIVERFRONT LN
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-9527
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2224 RIVERFRONT LN
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-9527
Practice Address - Country:US
Practice Address - Phone:501-538-9601
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-24
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-94342084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty