Healthcare Provider Details

I. General information

NPI: 1174174775
Provider Name (Legal Business Name): NICHOLAS SIMPSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2019
Last Update Date: 09/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8857 LADUE ROAD
ST. LOUIS MO
63124
US

IV. Provider business mailing address

8857 LADUE ROAD
ST. LOUIS MO
63124
US

V. Phone/Fax

Practice location:
  • Phone: 314-576-8189
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2019034298
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: