MEDICARE: MRS. LYNN RAE NICHOLS M.S CCC-SLP, M. ED

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	235Z00000X	Speech-Language Pathologist	01013	MO

General Provider Information

NPI Number	:	1548967797
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LYNN RAE NICHOLS M.S CCC-SLP, M. ED

Provider Business Mailing Address
First Line	:	3231 FAIRVIEW LN
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63129-1760
Country	:	US
Telephone Number	:	314-680-5770
Fax Number	:

Provider Business Practice Location Address
First Line	:	3231 FAIRVIEW LN
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63129-1760
Country	:	US
Telephone Number	:	314-680-5770
Fax Number	:

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

Provider Enumeration Date	:	02/08/2023
Last Update Date	:	02/08/2023

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