Provider Demographics
NPI:1700109816
Name:NICHOLAS, TRISHA JO (RN)
Entity Type:Individual
Prefix:
First Name:TRISHA
Middle Name:JO
Last Name:NICHOLAS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 DONS WAY
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71913-6478
Mailing Address - Country:US
Mailing Address - Phone:501-624-7111
Mailing Address - Fax:501-620-5109
Practice Address - Street 1:1615 MLK BLVD
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:AR
Practice Address - Zip Code:72104-2233
Practice Address - Country:US
Practice Address - Phone:501-332-5236
Practice Address - Fax:501-620-5109
Is Sole Proprietor?:No
Enumeration Date:2010-03-03
Last Update Date:2010-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR73728163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR116399726Medicaid