Provider Demographics
NPI:1548682339
Name:HANCOCK, NICOLE L (RD)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:L
Last Name:HANCOCK
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1084 COUNTY ROAD 2630
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:MO
Mailing Address - Zip Code:65560-7967
Mailing Address - Country:US
Mailing Address - Phone:417-547-3373
Mailing Address - Fax:
Practice Address - Street 1:35629 HIGHWAY 72
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:MO
Practice Address - Zip Code:65560-7217
Practice Address - Country:US
Practice Address - Phone:573-729-5917
Practice Address - Fax:573-729-5636
Is Sole Proprietor?:No
Enumeration Date:2014-01-13
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2460133V00000X
MO2010033235133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO350081231Medicaid
MO0957151OtherCIGNA PID
MO26D0446923OtherCLIA (TCMH)
MO003775591OtherUHC MPIN