Provider Demographics
NPI:1205389871
Name:FELLOWS, NICOLE (PT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:FELLOWS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:491 CATTLE DRIVE CIR STE 3
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29588-3732
Mailing Address - Country:US
Mailing Address - Phone:309-360-2480
Mailing Address - Fax:
Practice Address - Street 1:491 CATTLE DRIVE CIR STE 3
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29588-3732
Practice Address - Country:US
Practice Address - Phone:309-360-2480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-29
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC11957225100000X
CT11044225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty