Provider Demographics
NPI:1053490508
Name:NICKERSON, NANCY J (AHCNS)
Entity Type:Individual
Prefix:MS
First Name:NANCY
Middle Name:J
Last Name:NICKERSON
Suffix:
Gender:F
Credentials:AHCNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60352
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63160-0352
Mailing Address - Country:US
Mailing Address - Phone:314-362-7260
Mailing Address - Fax:314-362-6288
Practice Address - Street 1:4921 PARKVIEW PL
Practice Address - Street 2:DIV SURG CT ADULT CARDIO, STE 8A
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1032
Practice Address - Country:US
Practice Address - Phone:314-362-7260
Practice Address - Fax:314-362-6288
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO068264364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO420061225Medicaid