1003811258 NPI number — MISS KELLEY NICOLE TATE P.T.

Table of content: MISS KELLEY NICOLE TATE P.T. (NPI 1003811258)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003811258 NPI number — MISS KELLEY NICOLE TATE P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TATE
Provider First Name:
KELLEY
Provider Middle Name:
NICOLE
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
P.T.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MALANEY
Provider Other First Name:
KELLEY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1003811258
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/20/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4501 S HARVEST RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBIA
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65203-8764
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-474-5098
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1420 W ASHLEY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOONVILLE
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65233-2112
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
660-882-6115
Provider Business Practice Location Address Fax Number:
660-882-6120
Provider Enumeration Date:
06/15/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  2002025550 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 484700802 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 650025700 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 122566 . This is a "BCBS" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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