Healthcare Provider Details

I. General information

NPI: 1447033303
Provider Name (Legal Business Name): NICOLE M POPPA HIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE M BRIGGS

II. Dates (important events)

Enumeration Date: 08/15/2023
Last Update Date: 08/15/2023
Certification Date: 08/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 E TORRANCE ST
MARYVILLE MO
64468-2348
US

IV. Provider business mailing address

101 S BALTIMORE ST
KIRKSVILLE MO
63501-3749
US

V. Phone/Fax

Practice location:
  • Phone: 660-665-9114
  • Fax: 573-756-0505
Mailing address:
  • Phone: 660-665-9114
  • Fax: 573-756-0505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number2023033247
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: