Healthcare Provider Details

I. General information

NPI: 1427562123
Provider Name (Legal Business Name): JUSTIN NICHOLS RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2017
Last Update Date: 05/18/2023
Certification Date: 05/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 W 39TH ST
KANSAS CITY MO
64111-2910
US

IV. Provider business mailing address

600 W 39TH ST
KANSAS CITY MO
64111-2910
US

V. Phone/Fax

Practice location:
  • Phone: 816-421-7608
  • Fax: 816-421-6493
Mailing address:
  • Phone: 816-421-7608
  • Fax: 816-421-6493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number2013025569
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number2013025569
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: