Provider Demographics
NPI:1083940548
Name:BOYLE, NICOLE DESHEA
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:DESHEA
Last Name:BOYLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11306 MCCULLOUGH RD
Mailing Address - Street 2:
Mailing Address - City:ZACHARY
Mailing Address - State:LA
Mailing Address - Zip Code:70791-8712
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10742 OAKLINE DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-3317
Practice Address - Country:US
Practice Address - Phone:225-635-2448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-19
Last Update Date:2009-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAA4903225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant