Healthcare Provider Details

I. General information

NPI: 1811596877
Provider Name (Legal Business Name): STEPHANIE R NICHOLSON FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2020
Last Update Date: 03/30/2026
Certification Date: 03/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1109 W CLAY RD
VERSAILLES MO
65084-1177
US

IV. Provider business mailing address

305 W MAIN ST
SEDALIA MO
65301-3821
US

V. Phone/Fax

Practice location:
  • Phone: 573-378-2351
  • Fax: 660-826-1300
Mailing address:
  • Phone: 660-310-0909
  • Fax: 888-979-8868

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2020040319
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: