Provider Demographics
NPI:1053902627
Name:MENICHINO, NICOLE (NP)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MENICHINO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16216 BAXTER RD STE 100
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-4778
Mailing Address - Country:US
Mailing Address - Phone:636-449-4700
Mailing Address - Fax:636-449-2595
Practice Address - Street 1:16216 BAXTER RD STE 100
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-4778
Practice Address - Country:US
Practice Address - Phone:636-449-4700
Practice Address - Fax:636-449-2595
Is Sole Proprietor?:No
Enumeration Date:2021-01-27
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016004551163W00000X
MO2021004371363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse