=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912632803
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EMMA NICHOLS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2022
-----------------------------------------------------
Last Update Date | 01/28/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 999 S COOPER ST APT 202
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38104-5669
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-765-1828
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 954 BERGEN ST
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11216-4869
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-765-1828
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 032522
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------