Healthcare Provider Details

I. General information

NPI: 1447360680
Provider Name (Legal Business Name): DONNA NICKS RPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 09/19/2022
Certification Date: 09/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1848 BEM CHURCH RD
OWENSVILLE MO
65066-3212
US

IV. Provider business mailing address

1848 BEM CHURCH RD
OWENSVILLE MO
65066-3212
US

V. Phone/Fax

Practice location:
  • Phone: 573-832-2288
  • Fax: 573-832-2288
Mailing address:
  • Phone: 573-832-2288
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number01264
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: