Provider Demographics
NPI:1336503044
Name:ACKERMANN, NICOLE (ATC/ LAT ITAT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:ACKERMANN
Suffix:
Gender:F
Credentials:ATC/ LAT ITAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 CASPER AVE
Mailing Address - Street 2:
Mailing Address - City:NEWCASTLE
Mailing Address - State:WY
Mailing Address - Zip Code:82701-2705
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:116 CASPER AVE
Practice Address - Street 2:
Practice Address - City:NEWCASTLE
Practice Address - State:WY
Practice Address - Zip Code:82701-2705
Practice Address - Country:US
Practice Address - Phone:307-746-2713
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-08
Last Update Date:2016-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY642255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer