MEDICARE: NICOLE MARSHALL-EBERSOLE APN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2200X	Adult Health Nurse Practitioner	2014010129	MO
2	363LP2300X	Primary Care Nurse Practitioner	53-76330-122	KS

General Provider Information

NPI Number	:	1831501592
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE MARSHALL-EBERSOLE APN

Provider Business Mailing Address
First Line	:	2121 CENTRAL ST APT 602
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64108-2070
Country	:	US
Telephone Number	:	973-568-5127
Fax Number	:

Provider Business Practice Location Address
First Line	:	2121 CENTRAL ST APT 602
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64108-2070
Country	:	US
Telephone Number	:	973-568-5127
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/28/2014
Last Update Date	:	05/28/2014

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