Provider Demographics
NPI:1063679025
Name:BARE, NICOLE TRAYLOR (COTA/L-RN)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:TRAYLOR
Last Name:BARE
Suffix:
Gender:F
Credentials:COTA/L-RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 KING JAMES WAY
Mailing Address - Street 2:
Mailing Address - City:PIKEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27863-8398
Mailing Address - Country:US
Mailing Address - Phone:252-560-8947
Mailing Address - Fax:
Practice Address - Street 1:2401 WAYNE MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27534-1727
Practice Address - Country:US
Practice Address - Phone:919-736-7093
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-19
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC188234163W00000X
NC3363224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No163W00000XNursing Service ProvidersRegistered Nurse