Healthcare Provider Details

I. General information

NPI: 1174479307
Provider Name (Legal Business Name): NICOLE MARIE BONDURANT DNP, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2026
Last Update Date: 03/09/2026
Certification Date: 03/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 BOLAND PL APT 1024
SAINT LOUIS MO
63117-2180
US

IV. Provider business mailing address

1325 BOLAND PL APT 1024
SAINT LOUIS MO
63117-2180
US

V. Phone/Fax

Practice location:
  • Phone: 314-602-1202
  • Fax:
Mailing address:
  • Phone: 314-602-1202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2018035085
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: