Provider Demographics
NPI:1992240758
Name:NICOLA, CHRISTINE (NP)
Entity type:Individual
Prefix:MS
First Name:CHRISTINE
Middle Name:
Last Name:NICOLA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60352
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63160-0352
Mailing Address - Country:US
Mailing Address - Phone:314-362-5641
Mailing Address - Fax:314-362-0369
Practice Address - Street 1:4921 PARKVIEW PL
Practice Address - Street 2:DIV PA LAB AND GENOMIC MED, STE 4E
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1032
Practice Address - Country:US
Practice Address - Phone:314-362-5641
Practice Address - Fax:314-362-0369
Is Sole Proprietor?:No
Enumeration Date:2017-01-03
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1166662363LP0808X
MO2016038516363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO420046606Medicaid