Healthcare Provider Details

I. General information

NPI: 1700109816
Provider Name (Legal Business Name): TRISHA JO NICHOLAS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2010
Last Update Date: 03/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1615 MLK BLVD
MALVERN AR
72104-2233
US

IV. Provider business mailing address

125 DONS WAY
HOT SPRINGS AR
71913-6478
US

V. Phone/Fax

Practice location:
  • Phone: 501-332-5236
  • Fax: 501-620-5109
Mailing address:
  • Phone: 501-624-7111
  • Fax: 501-620-5109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR73728
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: