Provider Demographics
NPI:1477031581
Name:KWAK, NICOLE (AUD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:
Last Name:KWAK
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 BALA AVE
Mailing Address - Street 2:
Mailing Address - City:BALA CYNWYD
Mailing Address - State:PA
Mailing Address - Zip Code:19004-3317
Mailing Address - Country:US
Mailing Address - Phone:610-747-1110
Mailing Address - Fax:610-747-1118
Practice Address - Street 1:143 BALA AVE
Practice Address - Street 2:
Practice Address - City:BALA CYNWYD
Practice Address - State:PA
Practice Address - Zip Code:19004-3317
Practice Address - Country:US
Practice Address - Phone:610-747-1110
Practice Address - Fax:610-747-1118
Is Sole Proprietor?:No
Enumeration Date:2018-07-31
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAAT006582237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter