=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609316694
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUZANNE NICHOLAS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/24/2017
-----------------------------------------------------
Last Update Date | 02/24/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2224 RIVERFRONT LN
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72703-9527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-538-9601
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2224 RIVERFRONT LN
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72703-9527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MD
-----------------------------------------------------
Name | SUZANNE NICHOLAS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 501-538-9601
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | E-9434
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------