Provider Demographics
NPI:1497286462
Name:DAVOLT, NICOLE (PROVIDER)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:DAVOLT
Suffix:
Gender:F
Credentials:PROVIDER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 N JOHNSON ST.
Mailing Address - Street 2:
Mailing Address - City:KAHOKA
Mailing Address - State:MO
Mailing Address - Zip Code:63445
Mailing Address - Country:US
Mailing Address - Phone:319-931-4237
Mailing Address - Fax:
Practice Address - Street 1:112 N JOHNSON ST.
Practice Address - Street 2:
Practice Address - City:KAHOKA
Practice Address - State:MO
Practice Address - Zip Code:63445
Practice Address - Country:US
Practice Address - Phone:319-931-4237
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-22
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker