Provider Demographics
NPI:1235473380
Name:BORRENPOHL, NICOLE DANIELLE (NP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:DANIELLE
Last Name:BORRENPOHL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22154 HIGHWAY 179
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:MO
Mailing Address - Zip Code:65046-2332
Mailing Address - Country:US
Mailing Address - Phone:618-214-8258
Mailing Address - Fax:573-632-5875
Practice Address - Street 1:2505 MISSION DR STE 320
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-9508
Practice Address - Country:US
Practice Address - Phone:573-681-3767
Practice Address - Fax:573-681-3593
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR202111135NP-PP363LP0808X
MO2018009727363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA4911119Medicare UPIN