Healthcare Provider Details

I. General information

NPI: 1023460623
Provider Name (Legal Business Name): NICHOLE J RODROCK CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2016
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5571 GRETNA RD STE B
BRANSON MO
65616-7294
US

IV. Provider business mailing address

5571 GRETNA RD STE B
BRANSON MO
65616-7294
US

V. Phone/Fax

Practice location:
  • Phone: 417-243-2300
  • Fax:
Mailing address:
  • Phone: 417-243-2300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2016022462
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: