Healthcare Provider Details

I. General information

NPI: 1700714771
Provider Name (Legal Business Name): NICHOLE MARY GLORE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2026
Last Update Date: 05/11/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6944 BLUFF SPRINGS CT
SAINT LOUIS MO
63129-5462
US

IV. Provider business mailing address

6944 BLUFF SPRINGS CT
SAINT LOUIS MO
63129-5462
US

V. Phone/Fax

Practice location:
  • Phone: 314-814-7115
  • Fax:
Mailing address:
  • Phone: 314-814-7115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: