Provider Demographics
NPI:1073015715
Name:MINNIS, NICOLE (AT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MINNIS
Suffix:
Gender:F
Credentials:AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 HYNES CT
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03839-5432
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11 HYNES CT
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03839-5432
Practice Address - Country:US
Practice Address - Phone:603-339-0416
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-07
Last Update Date:2018-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0808021542255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer