Individual
MISS KELLEY NICOLE TATE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
P.T.
Contact information
Practice address
1420 W ASHLEY RD, BOONVILLE, MO 65233-2112
(660) 882-6115
(660) 882-6120
Mailing address
4501 S HARVEST RD, COLUMBIA, MO 65203-8764
(573) 474-5098
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
2002025550
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
122566
BCBS
MO
05
—
484700802
—
MO
01
—
650025700
MEDICARE RAILROAD
MO
Enumeration date
06/15/2005
Last updated
02/20/2025
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