Provider Demographics
NPI:1467654624
Name:STANTON, NICOLE PAULINE (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:PAULINE
Last Name:STANTON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:PAULINE
Other - Last Name:SIMONS (MAIDEN NAME)
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:75 LEROY GEORGE DR
Mailing Address - Street 2:
Mailing Address - City:CLYDE
Mailing Address - State:NC
Mailing Address - Zip Code:28721-7461
Mailing Address - Country:US
Mailing Address - Phone:828-452-8070
Mailing Address - Fax:828-452-8072
Practice Address - Street 1:75 LEROY GEORGE DR
Practice Address - Street 2:
Practice Address - City:CLYDE
Practice Address - State:NC
Practice Address - Zip Code:28721-7461
Practice Address - Country:US
Practice Address - Phone:828-452-8070
Practice Address - Fax:828-452-8072
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012508225X00000X
NC9216225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1467654624Medicaid
NY330079Medicare Oscar/Certification
NY141731786OtherHOSPITAL TAX ID #
NY012508OtherLICENSE
NY33U079Medicare ID - Type UnspecifiedHOSPITAL MCR SWING BED #