Provider Demographics
NPI:1144227091
Name:CARDILLO, NICOLE (OT/CHT)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:
Last Name:CARDILLO
Suffix:
Gender:F
Credentials:OT/CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91-1654 BURKE ST
Mailing Address - Street 2:
Mailing Address - City:EWA BEACH
Mailing Address - State:HI
Mailing Address - Zip Code:96706-2049
Mailing Address - Country:US
Mailing Address - Phone:808-285-5457
Mailing Address - Fax:757-321-3332
Practice Address - Street 1:95-390 KUAHELANI AVE
Practice Address - Street 2:1C
Practice Address - City:MILILANI
Practice Address - State:HI
Practice Address - Zip Code:96789-1192
Practice Address - Country:US
Practice Address - Phone:808-445-4428
Practice Address - Fax:806-637-9592
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119003304225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC05501OtherMEDICARE GROUP PTAN
VAANTHEM BC/BSOther278740