Provider Demographics
NPI:1831501592
Name:MARSHALL-EBERSOLE, NICOLE (APN)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MARSHALL-EBERSOLE
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2121 CENTRAL ST APT 602
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64108-2070
Mailing Address - Country:US
Mailing Address - Phone:973-568-5127
Mailing Address - Fax:
Practice Address - Street 1:2121 CENTRAL ST APT 602
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64108-2070
Practice Address - Country:US
Practice Address - Phone:973-568-5127
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-28
Last Update Date:2014-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014010129363LA2200X
KS53-76330-122363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care