Provider Demographics
NPI:1205532819
Name:BALDERSTON, NICOLE LYNN (MS, LAT, ATC)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:LYNN
Last Name:BALDERSTON
Suffix:
Gender:F
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5625 W 134TH PL APT 2037
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66209-4064
Mailing Address - Country:US
Mailing Address - Phone:785-819-1129
Mailing Address - Fax:
Practice Address - Street 1:1950 DIAMOND PKWY
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64116-4328
Practice Address - Country:US
Practice Address - Phone:816-561-3003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-06
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20190324632255A2300X
KS24-014542255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2019032463OtherAT LINCENSE
KS24-01454OtherAT LICENSE
2000015152OtherNATA BOC