Provider Demographics
NPI:1497289771
Name:LANCASTER, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:LANCASTER
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 1:102 DONALD ST
Mailing Address - Street 2:
Mailing Address - City:SAINT MARYS
Mailing Address - State:WV
Mailing Address - Zip Code:26170-9630
Mailing Address - Country:US
Mailing Address - Phone:304-893-3231
Mailing Address - Fax:
Practice Address - Street 1:102 DONALD STREET
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:WV
Practice Address - Zip Code:26170
Practice Address - Country:US
Practice Address - Phone:304-893-3231
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-13
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOTA003584224Z00000X
WVC1386224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant