Provider Demographics
NPI:1184339533
Name:MCPHEARSON, ANTINIECE NICOLE
Entity type:Individual
Prefix:
First Name:ANTINIECE
Middle Name:NICOLE
Last Name:MCPHEARSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4056 FINNEY AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63113-3426
Mailing Address - Country:US
Mailing Address - Phone:314-728-0474
Mailing Address - Fax:
Practice Address - Street 1:505 E KALAMAZOO AVE STE A
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-3873
Practice Address - Country:US
Practice Address - Phone:314-728-0474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-19
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021036978164W00000X
376K00000X
MO141824376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
No164W00000XNursing Service ProvidersLicensed Practical Nurse