Provider Demographics
NPI:1275044497
Name:MITCHELL, NICOLE (PTA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1211 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68801-4407
Mailing Address - Country:US
Mailing Address - Phone:402-460-0243
Mailing Address - Fax:
Practice Address - Street 1:78078 COUNTRY CLUB DR
Practice Address - Street 2:
Practice Address - City:BERMUDA DUNES
Practice Address - State:CA
Practice Address - Zip Code:92203-8173
Practice Address - Country:US
Practice Address - Phone:760-345-9934
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-15
Last Update Date:2017-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPTA48584225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NEFLJ899323208OtherBLUE CROSS BLUE SHIELD