Provider Demographics
NPI:1124560933
Name:FOGTMAN, NICOLE CELESTE (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:CELESTE
Last Name:FOGTMAN
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:CELESTE
Other - Last Name:REYNOLDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:2615 E RANDOLPH AVE
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73701-4670
Mailing Address - Country:US
Mailing Address - Phone:412-420-7164
Mailing Address - Fax:580-234-2615
Practice Address - Street 1:2615 E RANDOLPH AVE
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701-4670
Practice Address - Country:US
Practice Address - Phone:412-420-7164
Practice Address - Fax:580-234-2615
Is Sole Proprietor?:No
Enumeration Date:2016-11-09
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6075235Z00000X
OK5495235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist