Healthcare Provider Details

I. General information

NPI: 1093335416
Provider Name (Legal Business Name): MELISSA NIENHUIS LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2020
Last Update Date: 04/26/2020
Certification Date: 04/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 S KEENEY ST
COLE CAMP MO
65325-1059
US

IV. Provider business mailing address

8166 BOULDER RD
VERSAILLES MO
65084-4939
US

V. Phone/Fax

Practice location:
  • Phone: 660-668-3751
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2016023475
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: