Provider Demographics
NPI:1427597715
Name:WEBBER, NICHOLE
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:
Last Name:WEBBER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2546
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-0917
Mailing Address - Country:US
Mailing Address - Phone:208-304-0652
Mailing Address - Fax:
Practice Address - Street 1:1218 N DIVISION AVE
Practice Address - Street 2:SITE 102
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-5054
Practice Address - Country:US
Practice Address - Phone:208-304-0652
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-20
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT60728364225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAOT60728364OtherWASHINGTON OCCUPATIONAL THERAPY LICENSE