Healthcare Provider Details

I. General information

NPI: 1114683281
Provider Name (Legal Business Name): NICOLE SMITH RD, LD, CPHT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: NICOLE PASTOR

II. Dates (important events)

Enumeration Date: 11/12/2021
Last Update Date: 11/12/2021
Certification Date: 11/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 E 5TH ST
FULTON MO
65251-1748
US

IV. Provider business mailing address

203 SHELLBARK DR
TROY MO
63379-3307
US

V. Phone/Fax

Practice location:
  • Phone: 573-592-4100
  • Fax:
Mailing address:
  • Phone: 636-734-1430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: