Healthcare Provider Details

I. General information

NPI: 1285260166
Provider Name (Legal Business Name): HAROLD THOMAS NICHOLSON RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2020
Last Update Date: 03/23/2020
Certification Date: 03/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4212 NE KENNESAW RDG
LEES SUMMIT MO
64064-1379
US

IV. Provider business mailing address

4212 NE KENNESAW RDG
LEES SUMMIT MO
64064-1379
US

V. Phone/Fax

Practice location:
  • Phone: 816-616-6376
  • Fax:
Mailing address:
  • Phone: 816-616-6376
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WI0500X
TaxonomyInfusion Therapy Registered Nurse
License Number108988
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: