Provider Demographics
NPI:1275021164
Name:NICKERSON, KRISTINA ANNE (COTA)
Entity Type:Individual
Prefix:MISS
First Name:KRISTINA
Middle Name:ANNE
Last Name:NICKERSON
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4218 US HIGHWAY 80 E APT 2067
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75149-1173
Mailing Address - Country:US
Mailing Address - Phone:254-205-1171
Mailing Address - Fax:
Practice Address - Street 1:930 W CENTERVILLE RD STE C
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75041-5854
Practice Address - Country:US
Practice Address - Phone:972-303-7021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-25
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX215045224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant