Provider Demographics
NPI:1548967797
Name:NICHOLS, LYNN RAE (MS CCC-SLP, M ED)
Entity type:Individual
Prefix:MRS
First Name:LYNN
Middle Name:RAE
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:MS CCC-SLP, M ED
Other - Prefix:MISS
Other - First Name:LYNN
Other - Middle Name:RAE
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3231 FAIRVIEW LN
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63129-1760
Mailing Address - Country:US
Mailing Address - Phone:314-680-5770
Mailing Address - Fax:
Practice Address - Street 1:3231 FAIRVIEW LN
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63129-1760
Practice Address - Country:US
Practice Address - Phone:314-680-5770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-08
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO01013235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist