Provider Demographics
NPI:1851895635
Name:NICOLES, SARA-NICOLE (CRNA)
Entity Type:Individual
Prefix:
First Name:SARA-NICOLE
Middle Name:
Last Name:NICOLES
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:
Other - Last Name:NICOLES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:6905 PLANTATION RD
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39565-9002
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6905 PLANTATION RD
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39565-9002
Practice Address - Country:US
Practice Address - Phone:205-441-5589
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-19
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10313-33367500000X
PARN704920163W00000X, 367500000X
MARN2341791367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110001680AMedicaid