Provider Demographics
NPI:1245424480
Name:STAUDER, NICOLE TONETTE (PT)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:TONETTE
Last Name:STAUDER
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 1:523 WATER ST
Mailing Address - Street 2:
Mailing Address - City:NOKOMIS
Mailing Address - State:IL
Mailing Address - Zip Code:62075-1444
Mailing Address - Country:US
Mailing Address - Phone:217-563-2813
Mailing Address - Fax:
Practice Address - Street 1:505 STEVENS ST.
Practice Address - Street 2:NOKOMIS REHABIITATION AND HEALTH CARE CENTER
Practice Address - City:NOKOMIS
Practice Address - State:IL
Practice Address - Zip Code:62075
Practice Address - Country:US
Practice Address - Phone:217-563-7725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-30
Last Update Date:2007-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist