Provider Demographics
NPI:1467107698
Name:NICOLL, LYNETTE KAY
Entity Type:Individual
Prefix:
First Name:LYNETTE
Middle Name:KAY
Last Name:NICOLL
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 891
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:AZ
Mailing Address - Zip Code:85939-0891
Mailing Address - Country:US
Mailing Address - Phone:928-243-8003
Mailing Address - Fax:
Practice Address - Street 1:345 N 2ND ST W
Practice Address - Street 2:
Practice Address - City:SNOWFLAKE
Practice Address - State:AZ
Practice Address - Zip Code:85937-5380
Practice Address - Country:US
Practice Address - Phone:928-243-8003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-16
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-11800225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist