Healthcare Provider Details

I. General information

NPI: 1184554792
Provider Name (Legal Business Name): NICOLE MINX LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2026
Last Update Date: 05/23/2026
Certification Date: 05/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10071 CRESCENT RD
POTOSI MO
63664-2040
US

IV. Provider business mailing address

10071 CRESCENT RD
POTOSI MO
63664-2040
US

V. Phone/Fax

Practice location:
  • Phone: 573-245-4447
  • Fax:
Mailing address:
  • Phone: 573-245-4447
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number2025041580
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: