Healthcare Provider Details

I. General information

NPI: 1992167803
Provider Name (Legal Business Name): NICOLE BROWN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2016
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2950 H HWY
FARMINGTON MO
63640-7047
US

IV. Provider business mailing address

3863 CLEVELAND AVE
SAINT LOUIS MO
63110-4009
US

V. Phone/Fax

Practice location:
  • Phone: 573-330-7047
  • Fax:
Mailing address:
  • Phone: 314-664-3927
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code374700000X
TaxonomyTechnician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number2015044228
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: