Healthcare Provider Details

I. General information

NPI: 1730900663
Provider Name (Legal Business Name): TAMMY R NICHOLS NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2024
Last Update Date: 11/09/2024
Certification Date: 11/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2179 STATE HIGHWAY 73
MACKS CREEK MO
65786-8228
US

IV. Provider business mailing address

2179 STATE HIGHWAY 73
MACKS CREEK MO
65786-8228
US

V. Phone/Fax

Practice location:
  • Phone: 660-428-5020
  • Fax:
Mailing address:
  • Phone: 660-428-5020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2024041853
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number2024041853
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: