Healthcare Provider Details

I. General information

NPI: 1407081532
Provider Name (Legal Business Name): MICHELLE ANN NOLPH ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2009
Last Update Date: 10/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

606 E BUCHANAN ST
CALIFORNIA MO
65018-1910
US

IV. Provider business mailing address

PO BOX 104240
JEFFERSON CITY MO
65110-4240
US

V. Phone/Fax

Practice location:
  • Phone: 573-796-3600
  • Fax:
Mailing address:
  • Phone: 573-635-5264
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number2000147957
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: