Provider Demographics
NPI:1043739204
Name:STAHL, NICOLE R (PTA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:R
Last Name:STAHL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 W DOUGLAS AVE STE 1040
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67202-3017
Mailing Address - Country:US
Mailing Address - Phone:1316-263-0003
Mailing Address - Fax:
Practice Address - Street 1:550 N ANDOVER RD
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:KS
Practice Address - Zip Code:67002-9712
Practice Address - Country:US
Practice Address - Phone:316-202-0195
Practice Address - Fax:316-202-0196
Is Sole Proprietor?:No
Enumeration Date:2017-09-19
Last Update Date:2017-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1402357225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant