Provider Demographics
NPI:1740204593
Name:NICHOLS, LAURIE E
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:E
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 1:1122 WALKER FIELD ROAD
Mailing Address - Street 2:
Mailing Address - City:MUNFORD
Mailing Address - State:TN
Mailing Address - Zip Code:38058-0000
Mailing Address - Country:US
Mailing Address - Phone:901-840-2500
Mailing Address - Fax:
Practice Address - Street 1:1997 HIGHWAY 51 S
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:TN
Practice Address - Zip Code:38019-3630
Practice Address - Country:US
Practice Address - Phone:901-476-8967
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7091363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3909794Medicaid
TN3909794Medicare ID - Type Unspecified
TN3909794Medicaid