Provider Demographics
NPI:1568669398
Name:SOMMERS, NICHOLE MARIE (PT, DPT, ATC)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:MARIE
Last Name:SOMMERS
Suffix:
Gender:F
Credentials:PT, DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4925 SOURIS ST
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503-0733
Mailing Address - Country:US
Mailing Address - Phone:701-730-1267
Mailing Address - Fax:
Practice Address - Street 1:1000 W CENTURY AVE
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-0913
Practice Address - Country:US
Practice Address - Phone:701-355-1295
Practice Address - Fax:701-323-7046
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-27
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1458225100000X
ND297-052255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1568669398OtherTRIWEST
ND51764Medicaid
NDP00436245OtherPGA
ND1568669398OtherBCBS
ND51764Medicaid