Provider Demographics
NPI:1962077768
Name:ROBINSON, NICOLE L (CRNA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:L
Last Name:ROBINSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2 GOOD SAMARITAN WAY STE 205
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-2476
Mailing Address - Country:US
Mailing Address - Phone:161-889-9386
Mailing Address - Fax:618-899-3558
Practice Address - Street 1:1125 MADISON ST
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65101-5227
Practice Address - Country:US
Practice Address - Phone:573-632-5357
Practice Address - Fax:573-632-5876
Is Sole Proprietor?:No
Enumeration Date:2021-05-24
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL041505649163W00000X
IL209023334367500000X
MO2023002813367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse