Provider Demographics
NPI:1841384344
Name:NICHOLSON, GRETCHEN LYNN (CRNA)
Entity Type:Individual
Prefix:MS
First Name:GRETCHEN
Middle Name:LYNN
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2336
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72654-2336
Mailing Address - Country:US
Mailing Address - Phone:870-424-7070
Mailing Address - Fax:870-424-6616
Practice Address - Street 1:624 HOSPITAL DR DEPT 4610
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-2955
Practice Address - Country:US
Practice Address - Phone:870-508-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0082487367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200068790AMedicaid
OKP00336656Medicare PIN
OK247611808Medicare PIN