Basic Information
| Provider Information | |||||||||
| NPI: | 1962832980 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NICHOALDS | ||||||||
| FirstName: | MEGAN | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1551 WALL ST | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | SAINT CHARLES | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633033539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6366692268 | ||||||||
| FaxNumber: | 3142098127 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 MEDICAL PLZ | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LAKE ST LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633671490 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6336252662 | ||||||||
| FaxNumber: | 6366251121 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2013 | ||||||||
| LastUpdateDate: | 02/12/2014 | ||||||||
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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 | 363LF0000X | 2008020336 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 2008020336 | 01 | MO | LICENSE | OTHER |