Provider Demographics
NPI:1558906750
Name:BROWN, NICOLE DAWN (PA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:DAWN
Last Name:BROWN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 US HIGHWAY 61
Mailing Address - Street 2:
Mailing Address - City:FESTUS
Mailing Address - State:MO
Mailing Address - Zip Code:63028-4100
Mailing Address - Country:US
Mailing Address - Phone:636-933-5337
Mailing Address - Fax:
Practice Address - Street 1:1400 US HIGHWAY 61
Practice Address - Street 2:
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028-4100
Practice Address - Country:US
Practice Address - Phone:636-933-5337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-12
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085007300363A00000X
MO2019036691363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant