Provider Demographics
NPI:1205231396
Name:NICOLAY, KATELYN (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:
Last Name:NICOLAY
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:KATELYN
Other - Middle Name:
Other - Last Name:PERSOAGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAT, ATC
Mailing Address - Street 1:PO BOX 6050
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58108-6050
Mailing Address - Country:US
Mailing Address - Phone:701-231-5777
Mailing Address - Fax:
Practice Address - Street 1:NORTH DAKOTA STATE UNIVERSITY
Practice Address - Street 2:1340 ADMINISTRATION AVE
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58108
Practice Address - Country:US
Practice Address - Phone:701-231-5777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-31
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA26842255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer