Provider Demographics
NPI:1154987097
Name:DETERT, NICKOLAI C (DNP, FNP-C)
Entity type:Individual
Prefix:DR
First Name:NICKOLAI
Middle Name:C
Last Name:DETERT
Suffix:
Gender:M
Credentials:DNP, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4921 PARKVIEW PL STE 14A
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1032
Mailing Address - Country:US
Mailing Address - Phone:314-454-8778
Mailing Address - Fax:
Practice Address - Street 1:4921 PARKVIEW PL STE 14A
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1032
Practice Address - Country:US
Practice Address - Phone:314-454-8778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-16
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019019665363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily