Provider Demographics
NPI:1659681328
Name:NICHOLS, CRYSTAL JO (CFNP)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:JO
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:285 IVIE LN
Mailing Address - Street 2:
Mailing Address - City:MANTACHIE
Mailing Address - State:MS
Mailing Address - Zip Code:38855-9764
Mailing Address - Country:US
Mailing Address - Phone:662-282-4197
Mailing Address - Fax:662-282-4197
Practice Address - Street 1:285 IVIE LN
Practice Address - Street 2:
Practice Address - City:MANTACHIE
Practice Address - State:MS
Practice Address - Zip Code:38855-9764
Practice Address - Country:US
Practice Address - Phone:662-282-4197
Practice Address - Fax:662-282-5121
Is Sole Proprietor?:No
Enumeration Date:2010-10-15
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR870294363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05372791Medicaid
MS302I509866Medicare Oscar/Certification