Provider Demographics
NPI:1154837516
Name:HERRLE, NICOLE ELIZABETH (PT)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:ELIZABETH
Last Name:HERRLE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:ELIZABETH
Other - Last Name:BOUSKA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 424
Mailing Address - Street 2:
Mailing Address - City:GYPSUM
Mailing Address - State:CO
Mailing Address - Zip Code:81637-0424
Mailing Address - Country:US
Mailing Address - Phone:970-690-9579
Mailing Address - Fax:
Practice Address - Street 1:0130 SUMMER MEADOW ST
Practice Address - Street 2:
Practice Address - City:GYPSUM
Practice Address - State:CO
Practice Address - Zip Code:81637-0424
Practice Address - Country:US
Practice Address - Phone:970-690-9579
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-21
Last Update Date:2017-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL.00109382251P0200X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics