Basic Information
| Provider Information | |||||||||
| NPI: | 1952935405 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NICHOLS | ||||||||
| FirstName: | COLLEEN | ||||||||
| MiddleName: | DIANE | ||||||||
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| Credential: | CPNP-PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1554 HERITAGE VALLEY DR | ||||||||
| Address2: | |||||||||
| City: | HIGH RIDGE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630491169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149419284 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1465 S GRAND BLVD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631041003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145775666 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2020 | ||||||||
| LastUpdateDate: | 11/03/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 2020006145 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
No ID Information.