Provider Demographics
NPI:1811547003
Name:NICHOLS, ROSE MARY (APRN FNP-C)
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:MARY
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:APRN FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 W WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:BLYTHEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72315-3256
Mailing Address - Country:US
Mailing Address - Phone:870-740-8612
Mailing Address - Fax:
Practice Address - Street 1:1400 N DIVISION ST
Practice Address - Street 2:
Practice Address - City:BLYTHEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72315-1438
Practice Address - Country:US
Practice Address - Phone:870-776-1054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-19
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA006223363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily