Provider Demographics
NPI:1962836551
Name:NICHOLS, NICOLE K (ANP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:K
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:K
Other - Last Name:HENDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:PO BOX 23340
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63156-3340
Mailing Address - Country:US
Mailing Address - Phone:314-543-5200
Mailing Address - Fax:314-543-5219
Practice Address - Street 1:10012 KENNERLY RD
Practice Address - Street 2:SUITE 101
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2197
Practice Address - Country:US
Practice Address - Phone:314-543-5200
Practice Address - Fax:314-543-5219
Is Sole Proprietor?:No
Enumeration Date:2013-08-30
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013036540363L00000X
MO2010021406163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO124510079Medicare PIN