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General NPI Number Information
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NPI Number | 1629569843
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Entity Type | Individual
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Provider Name | NICOLE RENEE NISSEN
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Gender | Female
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Dates
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Enumeration Date | 05/23/2018
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Last Update Date | 04/17/2025
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Provider Practice Location Address
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Address Line | 623 HAMACHER ST
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City | WATERLOO
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State | IL
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Zip | 62298-1786
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Country | US
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Telephone | 314-925-0903
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Fax |
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Provider Business Mailing Address
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Address Line | 10426 BAUR BLVD
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City | SAINT LOUIS
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State | MO
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Zip | 63132-1905
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Country | US
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Telephone | 314-925-0903
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 209017442
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 2018012260
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License Number State | MO
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