Provider Demographics
NPI:1538294277
Name:NICKELE, CORRI SUEKO (OTR L)
Entity Type:Individual
Prefix:MRS
First Name:CORRI
Middle Name:SUEKO
Last Name:NICKELE
Suffix:
Gender:F
Credentials:OTR L
Other - Prefix:MS
Other - First Name:CORRI
Other - Middle Name:SUEKO
Other - Last Name:YONAMINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6373 W GOLDEN LN
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85302-4437
Mailing Address - Country:US
Mailing Address - Phone:623-937-1676
Mailing Address - Fax:
Practice Address - Street 1:6373 W GOLDEN LN
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85302-4437
Practice Address - Country:US
Practice Address - Phone:623-937-1676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3074174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ3074OtherOCC. THERAPY LICENSE