Provider Demographics
NPI:1508864950
Name:SMITH, NICOLE BAILEY (MPT)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:BAILEY
Last Name:SMITH
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4725 MERLE HAY RD
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50322-1983
Mailing Address - Country:US
Mailing Address - Phone:155-331-3190
Mailing Address - Fax:515-462-1191
Practice Address - Street 1:820 W SUMMIT ST
Practice Address - Street 2:
Practice Address - City:WINTERSET
Practice Address - State:IA
Practice Address - Zip Code:50273-2206
Practice Address - Country:US
Practice Address - Phone:515-462-1999
Practice Address - Fax:515-462-1191
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA03536225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI7658OtherMEDICARE GROUP
IAPIN I11548Medicare ID - Type UnspecifiedMC PART B