Provider Demographics
NPI:1164548293
Name:NICKELL, LEAH DAWN (ATC, LAT)
Entity Type:Individual
Prefix:MRS
First Name:LEAH
Middle Name:DAWN
Last Name:NICKELL
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 FM 775
Mailing Address - Street 2:
Mailing Address - City:LA VERNIA
Mailing Address - State:TX
Mailing Address - Zip Code:78121-9554
Mailing Address - Country:US
Mailing Address - Phone:830-779-2181
Mailing Address - Fax:830-779-1021
Practice Address - Street 1:225 FM 775
Practice Address - Street 2:
Practice Address - City:LA VERNIA
Practice Address - State:TX
Practice Address - Zip Code:78121-9554
Practice Address - Country:US
Practice Address - Phone:830-779-2181
Practice Address - Fax:830-779-1021
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT19632255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer