Provider Demographics
NPI:1013550482
Name:BAKER, NICOLE LYNNE (NP-C)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:LYNNE
Last Name:BAKER
Suffix:
Gender:
Credentials:NP-C
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:LYNNE
Other - Last Name:GALLANT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:798 BENT TREE AVE
Mailing Address - Street 2:
Mailing Address - City:WILLARD
Mailing Address - State:MO
Mailing Address - Zip Code:65781-6003
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:798 BENT TREE AVE
Practice Address - Street 2:
Practice Address - City:WILLARD
Practice Address - State:MO
Practice Address - Zip Code:65781-6003
Practice Address - Country:US
Practice Address - Phone:000-000-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-17
Last Update Date:2025-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019039808363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2009028096OtherRN LICENSE
MO2019039808OtherNP LICENSE