Provider Demographics
NPI:1114087913
Name:GEORGE, NICCA A (PT)
Entity Type:Individual
Prefix:MS
First Name:NICCA
Middle Name:A
Last Name:GEORGE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6284 RUCKER RD
Mailing Address - Street 2:STE N
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-4865
Mailing Address - Country:US
Mailing Address - Phone:317-475-1389
Mailing Address - Fax:
Practice Address - Street 1:6284 RUCKER RD
Practice Address - Street 2:STE N
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-4865
Practice Address - Country:US
Practice Address - Phone:317-475-1389
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05000996A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN220970AMedicare ID - Type UnspecifiedINDIVIDUAL PROV NUMBER