Provider Demographics
NPI:1649879107
Name:BROWN, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:BROWN
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 1:1307 E NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:BELTON
Mailing Address - State:MO
Mailing Address - Zip Code:64012-5109
Mailing Address - Country:US
Mailing Address - Phone:816-318-0404
Mailing Address - Fax:
Practice Address - Street 1:1307 E NORTH AVE
Practice Address - Street 2:
Practice Address - City:BELTON
Practice Address - State:MO
Practice Address - Zip Code:64012-5109
Practice Address - Country:US
Practice Address - Phone:816-318-0404
Practice Address - Fax:816-318-0467
Is Sole Proprietor?:No
Enumeration Date:2020-10-25
Last Update Date:2020-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012022665183500000X
KS1-15777183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist