Healthcare Provider Details

I. General information

NPI: 1730619073
Provider Name (Legal Business Name): NICOLE MARIE TWEEDY PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2017
Last Update Date: 09/12/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 N KEENE ST STE 102
COLUMBIA MO
65201-8136
US

IV. Provider business mailing address

PO BOX 843966
KANSAS CITY MO
64184-3966
US

V. Phone/Fax

Practice location:
  • Phone: 573-884-2522
  • Fax: 573-884-9898
Mailing address:
  • Phone: 573-882-3300
  • Fax: 573-884-0943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2017020563
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number2017020563
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: