Basic Information
| Provider Information | |||||||||
| NPI: | 1629569843 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NISSEN | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | RENEE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 210 NE TUDOR RD | ||||||||
| Address2: | |||||||||
| City: | LEES SUMMIT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640865696 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8882563814 | ||||||||
| FaxNumber: | 8882569054 | ||||||||
| Practice Location | |||||||||
| Address1: | 121 SAINT LUKES CENTER DR STE 403 | ||||||||
| Address2: | |||||||||
| City: | CHESTERFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630173519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142056149 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2018 | ||||||||
| LastUpdateDate: | 02/17/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 209017442 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 2018012260 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.