Healthcare Provider Details

I. General information

NPI: 1982303764
Provider Name (Legal Business Name): NICOLE JO SHIELDS WHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2023
Last Update Date: 04/22/2024
Certification Date: 04/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 HITT ST
COLUMBIA MO
65212-0001
US

IV. Provider business mailing address

PO BOX 843966
KANSAS CITY MO
64184-3966
US

V. Phone/Fax

Practice location:
  • Phone: 573-499-6084
  • Fax: 573-499-6088
Mailing address:
  • Phone: 573-884-3300
  • Fax: 573-884-0943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number2024013769
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: