Provider Demographics
NPI:1356823058
Name:NICHOLLLS, WENDY LEE (PTA)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:LEE
Last Name:NICHOLLLS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:WENDY
Other - Middle Name:LEE
Other - Last Name:NICHOLLS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PTA
Mailing Address - Street 1:1235 BARNESWOOD LN
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48306-4113
Mailing Address - Country:US
Mailing Address - Phone:586-246-6282
Mailing Address - Fax:
Practice Address - Street 1:4949 COOLIDGE HWY
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-1026
Practice Address - Country:US
Practice Address - Phone:248-655-5660
Practice Address - Fax:248-655-5662
Is Sole Proprietor?:No
Enumeration Date:2018-08-30
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI55020008282081P0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPediatric Rehabilitation Medicine