Provider Demographics
NPI:1932859774
Name:NICHOLS, MALLORY BROOKE (FNP-C, CRNP)
Entity type:Individual
Prefix:MRS
First Name:MALLORY
Middle Name:BROOKE
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:FNP-C, CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:676 HEIBERGER LOOP
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:AL
Mailing Address - Zip Code:36756-6525
Mailing Address - Country:US
Mailing Address - Phone:205-394-9150
Mailing Address - Fax:
Practice Address - Street 1:809 UNIVERSITY BLVD E
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35401-2071
Practice Address - Country:US
Practice Address - Phone:205-759-7111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-25
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-144817363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily