Healthcare Provider Details

I. General information

NPI: 1558583088
Provider Name (Legal Business Name): CASEY A NICHOLS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 09/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 SUNSET DR STE F
LA GRANDE OR
97850-1260
US

IV. Provider business mailing address

PO BOX 3290
LA GRANDE OR
97850-7290
US

V. Phone/Fax

Practice location:
  • Phone: 541-663-3030
  • Fax: 541-975-5201
Mailing address:
  • Phone: 541-963-1967
  • Fax: 541-963-1837

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN 9178702
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number201706907NP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: