Healthcare Provider Details

I. General information

NPI: 1740883495
Provider Name (Legal Business Name): KAYLEIGH NISSLE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2020
Last Update Date: 11/25/2025
Certification Date: 11/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 E CHERRY ST
TROY MO
63379-1410
US

IV. Provider business mailing address

520 E CHERRY ST
TROY MO
63379-1410
US

V. Phone/Fax

Practice location:
  • Phone: 314-834-1400
  • Fax: 314-834-1430
Mailing address:
  • Phone: 314-834-1400
  • Fax: 314-834-1430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number250088
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2022022412
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: