Provider Demographics
NPI:1093066300
Name:BOYDSTON, NICOLE R (MOT, OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:R
Last Name:BOYDSTON
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11601 N HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64155-1581
Mailing Address - Country:US
Mailing Address - Phone:816-589-5695
Mailing Address - Fax:
Practice Address - Street 1:11601 N HARRISON ST
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64155-1581
Practice Address - Country:US
Practice Address - Phone:816-589-5695
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-26
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO113854225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist