Provider Demographics
NPI:1174714588
Name:NICKS, CHERYL LYNN (NNP)
Entity type:Individual
Prefix:
First Name:CHERYL
Middle Name:LYNN
Last Name:NICKS
Suffix:
Gender:F
Credentials:NNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 MEDICAL CTR. BLVD.
Mailing Address - Street 2:NICU
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072
Mailing Address - Country:US
Mailing Address - Phone:504-349-2427
Mailing Address - Fax:504-349-2426
Practice Address - Street 1:1101 MEDICAL CTR. BLVD.
Practice Address - Street 2:NICU
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072
Practice Address - Country:US
Practice Address - Phone:504-349-2427
Practice Address - Fax:504-349-2426
Is Sole Proprietor?:No
Enumeration Date:2007-08-09
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA01190363LN0000X
LAAP01190363LN0000X, 363LN0005X
LARN041131363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
No363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1134007Medicaid
MS08025373Medicaid
LA4C3677061Medicare PIN
MS08025373Medicaid
LA1134007Medicaid