Healthcare Provider Details

I. General information

NPI: 1972974244
Provider Name (Legal Business Name): NICHELLE ENATA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICHELLE HARRISON

II. Dates (important events)

Enumeration Date: 10/13/2015
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 MEMORIAL DR STE 340
BELLEVILLE IL
62226-5373
US

IV. Provider business mailing address

PO BOX 959203
SAINT LOUIS MO
63195-9203
US

V. Phone/Fax

Practice location:
  • Phone: 618-234-9884
  • Fax: 618-235-9020
Mailing address:
  • Phone: 618-234-9884
  • Fax: 618-235-9020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number2020017990
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number036178542
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: