Healthcare Provider Details

I. General information

NPI: 1487689782
Provider Name (Legal Business Name): GLORIA JEAN NICHOLS RNC, WHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 09/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7711 LOUIS PASTEUR DR SUITE 200
SAN ANTONIO TX
78229-3415
US

IV. Provider business mailing address

20109 REGENCY RUN
GARDEN RIDGE TX
78266-2346
US

V. Phone/Fax

Practice location:
  • Phone: 210-692-9500
  • Fax: 210-616-9304
Mailing address:
  • Phone: 210-651-1103
  • Fax: 210-616-9304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number241589
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: