Healthcare Provider Details

I. General information

NPI: 1386548543
Provider Name (Legal Business Name): BRANDI RENE NICKELS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2026
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

54 HOSPITAL DR
OSAGE BEACH MO
65065-3050
US

IV. Provider business mailing address

27311 HIGHWAY NN
LAQUEY MO
65534-7544
US

V. Phone/Fax

Practice location:
  • Phone: 573-348-8000
  • Fax:
Mailing address:
  • Phone: 573-586-9260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2026047807
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: