Provider Demographics
NPI:1003214982
Name:WILSON, NICOLE CLAIRE (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:CLAIRE
Last Name:WILSON
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:MISS
Other - First Name:NICOLE
Other - Middle Name:CLAIRE
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2508 GUNPOWDER RD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72227-3029
Mailing Address - Country:US
Mailing Address - Phone:520-240-3723
Mailing Address - Fax:
Practice Address - Street 1:2508 GUNPOWDER RD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72227-3029
Practice Address - Country:US
Practice Address - Phone:520-240-3723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-09
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROT-A962224Z00000X
AZ5669224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR207699721Medicaid