Provider Demographics
NPI:1649225103
Name:MANLIN, NICOLE (ANP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MANLIN
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14805 N OUTER 40 RD
Mailing Address - Street 2:SUITE 320
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-6060
Mailing Address - Country:US
Mailing Address - Phone:888-811-4677
Mailing Address - Fax:
Practice Address - Street 1:14855 N OUTER 40
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-2026
Practice Address - Country:US
Practice Address - Phone:636-532-0150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2017-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO137025363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO427588108Medicaid
MO427588108Medicaid
MO827863853Medicare ID - Type Unspecified