Basic Information
| Provider Information | |||||||||
| NPI: | 1487031159 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NICHOLS | ||||||||
| FirstName: | JENNIFER | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 844737 | ||||||||
| Address2: | ATT: IPM CREDENTIALING | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752844737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6103824943 | ||||||||
| FaxNumber: | 6108783965 | ||||||||
| Practice Location | |||||||||
| Address1: | 615 E OKLAHOMA AVE | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | ENID | ||||||||
| State: | OK | ||||||||
| PostalCode: | 737015952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802423870 | ||||||||
| FaxNumber: | 5802424046 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2015 | ||||||||
| LastUpdateDate: | 08/12/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 90378 | OK | N | Nursing Service Providers | Registered Nurse | 363LF0000X | 90378 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 200589510A | 05 | OK | MEDICAID |