Provider Demographics
NPI:1447033303
Name:POPPA, NICOLE M (HIS)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:POPPA
Suffix:
Gender:F
Credentials:HIS
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:M
Other - Last Name:BRIGGS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:101 S BALTIMORE ST
Mailing Address - Street 2:
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63501-3749
Mailing Address - Country:US
Mailing Address - Phone:660-665-9114
Mailing Address - Fax:573-756-0505
Practice Address - Street 1:102 E TORRANCE ST
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:MO
Practice Address - Zip Code:64468-2348
Practice Address - Country:US
Practice Address - Phone:660-665-9114
Practice Address - Fax:573-756-0505
Is Sole Proprietor?:No
Enumeration Date:2023-08-15
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023033247237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2023033247OtherSTATE LICENSE