Provider Demographics
NPI:1326112988
Name:AMOS, NICOLE A (PT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:A
Last Name:AMOS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:A
Other - Last Name:MARTENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2609 LAUREN LAKE DR
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62221-8620
Mailing Address - Country:US
Mailing Address - Phone:618-960-6407
Mailing Address - Fax:
Practice Address - Street 1:210 HARTMAN LN STE 500
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1783
Practice Address - Country:US
Practice Address - Phone:618-589-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.016637225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist