Provider Demographics
NPI:1033484084
Name:HERDA, NICOLE LYNN (DPT)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:LYNN
Last Name:HERDA
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 32ND AVE NE
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59404-1065
Mailing Address - Country:US
Mailing Address - Phone:406-453-6060
Mailing Address - Fax:
Practice Address - Street 1:2900 10TH AVE S
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59405-3243
Practice Address - Country:US
Practice Address - Phone:406-453-0360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-08
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTPTP-PT-LIC-1727225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist