Provider Demographics
NPI:1104019850
Name:AXTHELM, NANCY ANN (CCCSLP)
Entity Type:Individual
Prefix:MRS
First Name:NANCY
Middle Name:ANN
Last Name:AXTHELM
Suffix:
Gender:F
Credentials:CCCSLP
Other - Prefix:
Other - First Name:NANCY
Other - Middle Name:
Other - Last Name:WALTERS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2901
Mailing Address - Street 2:
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414-5213
Mailing Address - Country:US
Mailing Address - Phone:307-527-7060
Mailing Address - Fax:307-587-2497
Practice Address - Street 1:808 NORTH STREET
Practice Address - Street 2:
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414-5213
Practice Address - Country:US
Practice Address - Phone:307-527-7060
Practice Address - Fax:307-587-2497
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-24
Last Update Date:2007-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYSP158235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1770688871Medicaid