Provider Demographics
NPI:1740400407
Name:NICKELL, STEPHEN MICHAEL JR (MA, ATC)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:MICHAEL
Last Name:NICKELL
Suffix:JR
Gender:M
Credentials:MA, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2142 KENNETH DR
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-1863
Mailing Address - Country:US
Mailing Address - Phone:937-631-4660
Mailing Address - Fax:
Practice Address - Street 1:1 UNIVERSITY PLZ
Practice Address - Street 2:MS 7650
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-4710
Practice Address - Country:US
Practice Address - Phone:573-986-6841
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2014-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20120285302255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer