Provider Demographics
NPI:1679336630
Name:NICHOLS, AMANDA EVANS
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:EVANS
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:745 N 25TH ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85213-6898
Mailing Address - Country:US
Mailing Address - Phone:840-241-1842
Mailing Address - Fax:
Practice Address - Street 1:738 S LONGMORE
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-1908
Practice Address - Country:US
Practice Address - Phone:480-472-4360
Practice Address - Fax:480-472-4350
Is Sole Proprietor?:No
Enumeration Date:2024-02-02
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ24725391163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse