1518116649 NPI number — NICOLE MCCAULEY PHD

Table of content: NICOLE MCCAULEY PHD (NPI 1518116649)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518116649 NPI number — NICOLE MCCAULEY PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCCAULEY
Provider First Name:
NICOLE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GARNER
Provider Other First Name:
NICOLE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PHD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1518116649
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/18/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
110 W OTIS AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALINA
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
67401-8713
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
979-492-2795
Provider Business Mailing Address Fax Number:
979-232-2135

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3212 E NETTLETON
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
JONESBORO
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72401-5451
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
785-825-0541
Provider Business Practice Location Address Fax Number:
785-825-0062
Provider Enumeration Date:
09/12/2008

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: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X , with the licence number: 2643-C , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 116378726 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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