Provider Demographics
NPI:1962664730
Name:MCNICHOLAS, COLLEEN PATRICIA (DO)
Entity Type:Individual
Prefix:DR
First Name:COLLEEN
Middle Name:PATRICIA
Last Name:MCNICHOLAS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:660 S EUCLID AVE
Mailing Address - Street 2:C B 8064
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1010
Mailing Address - Country:US
Mailing Address - Phone:314-454-7882
Mailing Address - Fax:314-222-6245
Practice Address - Street 1:4901 FOREST PARK AVE STE 710
Practice Address - Street 2:STE 710
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-1402
Practice Address - Country:US
Practice Address - Phone:314-362-4211
Practice Address - Fax:314-362-0049
Is Sole Proprietor?:No
Enumeration Date:2008-07-01
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011003938207V00000X, 207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1962664730Medicaid
ILENROLLEDMedicaid