Provider Demographics
NPI:1174666895
Name:MEMBER, NICOLE KIMBERLY (ATC)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:KIMBERLY
Last Name:MEMBER
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:184 DELL PL
Mailing Address - Street 2:
Mailing Address - City:STANHOPE
Mailing Address - State:NJ
Mailing Address - Zip Code:07874-2735
Mailing Address - Country:US
Mailing Address - Phone:973-951-9424
Mailing Address - Fax:
Practice Address - Street 1:165 WHIPPANY RD
Practice Address - Street 2:
Practice Address - City:WHIPPANY
Practice Address - State:NJ
Practice Address - Zip Code:07981-1741
Practice Address - Country:US
Practice Address - Phone:973-887-3004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MT001118002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer