Provider Demographics
NPI:1760453369
Name:HUCKABEE, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:HUCKABEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:LUSK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSN, APRN, BC-FNP
Mailing Address - Street 1:PO BOX 801143
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64180-1143
Mailing Address - Country:US
Mailing Address - Phone:573-331-3000
Mailing Address - Fax:573-331-5073
Practice Address - Street 1:1702 N KINGSHIGHWAY ST
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-2122
Practice Address - Country:US
Practice Address - Phone:573-339-0483
Practice Address - Fax:573-339-1876
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO137973363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO934359Medicare UPIN
MO000080995Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER