Provider Demographics
NPI:1407271315
Name:WENZLICK, NICOLE (PT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:WENZLICK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:676 MIAMI ST
Mailing Address - Street 2:
Mailing Address - City:TIFFIN
Mailing Address - State:OH
Mailing Address - Zip Code:44883-1934
Mailing Address - Country:US
Mailing Address - Phone:419-448-5533
Mailing Address - Fax:419-448-5559
Practice Address - Street 1:803 BREWFIELD DR
Practice Address - Street 2:
Practice Address - City:WAPAKONETA
Practice Address - State:OH
Practice Address - Zip Code:45895-9394
Practice Address - Country:US
Practice Address - Phone:419-738-7763
Practice Address - Fax:419-738-4322
Is Sole Proprietor?:No
Enumeration Date:2014-02-28
Last Update Date:2014-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH12205225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH12205OtherOHIO LICENSE