Provider Demographics
NPI:1669024931
Name:NICOLAS, CHANTAL (NP)
Entity Type:Individual
Prefix:
First Name:CHANTAL
Middle Name:
Last Name:NICOLAS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 W PLEASANT GROVE RD STE 101
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758-7034
Mailing Address - Country:US
Mailing Address - Phone:479-326-8525
Mailing Address - Fax:479-202-0501
Practice Address - Street 1:2301 W PLEASANT GROVE RD STE 101
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-7034
Practice Address - Country:US
Practice Address - Phone:479-326-8525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-16
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA005639363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily