Healthcare Provider Details

I. General information

NPI: 1740400407
Provider Name (Legal Business Name): STEPHEN MICHAEL NICKELL JR. M.A., ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 04/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 UNIVERSITY PLZ MS 7650
CAPE GIRARDEAU MO
63701-4710
US

IV. Provider business mailing address

2142 KENNETH DR
CAPE GIRARDEAU MO
63701-1863
US

V. Phone/Fax

Practice location:
  • Phone: 573-986-6841
  • Fax:
Mailing address:
  • Phone: 937-631-4660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2012028530
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: