Provider Demographics
NPI:1558615625
Name:NICELY, MELISSA (MPT)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:NICELY
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 1:103697 S PROGRESS RD
Mailing Address - Street 2:
Mailing Address - City:MEEKER
Mailing Address - State:OK
Mailing Address - Zip Code:74855-5507
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:103697 S PROGRESS RD
Practice Address - Street 2:
Practice Address - City:MEEKER
Practice Address - State:OK
Practice Address - Zip Code:74855-5507
Practice Address - Country:US
Practice Address - Phone:405-202-8453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-29
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3555225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist