MEDICARE: MRS. MARIANNE NICHOLS RNC WHNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WX0002X	High-Risk Obstetric Registered Nurse	510096	TX
2	363LW0102X	Women's Health Nurse Practitioner	510096	TX

General Provider Information

NPI Number	:	1285733758
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARIANNE NICHOLS RNC WHNP

Provider Business Mailing Address
First Line	:	PO BOX 3662
Second Line	:
City	:	LONGVIEW
State	:	TX
Zip	:	75606-3662
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	109 ZEID BLVD
Second Line	:
City	:	HENDERSON
State	:	TX
Zip	:	75652-6070
Country	:	US
Telephone Number	:	903-655-4200
Fax Number	:	903-655-4353

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/21/2006
Last Update Date	:	10/11/2021

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