Provider Demographics
NPI:1184404055
Name:LANDAU, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:LANDAU
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 1:3473 RIDER TRL S
Mailing Address - Street 2:
Mailing Address - City:EARTH CITY
Mailing Address - State:MO
Mailing Address - Zip Code:63045-1110
Mailing Address - Country:US
Mailing Address - Phone:314-328-0088
Mailing Address - Fax:
Practice Address - Street 1:911 STATE RTE 3
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IL
Practice Address - Zip Code:62298
Practice Address - Country:US
Practice Address - Phone:618-844-1401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-29
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021031918237700000X
IL237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist