Healthcare Provider Details

I. General information

NPI: 1558117630
Provider Name (Legal Business Name): NICOLE C BAILEY RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2024
Last Update Date: 04/29/2024
Certification Date: 04/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 W LAFAYETTE ST
VERSAILLES MO
65084-1346
US

IV. Provider business mailing address

104 W LAFAYETTE ST
VERSAILLES MO
65084-1346
US

V. Phone/Fax

Practice location:
  • Phone: 573-378-5438
  • Fax:
Mailing address:
  • Phone: 573-378-5438
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2010003365
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: