Provider Demographics
NPI:1598284630
Name:TABATT-TAYLOR, NICHOLE ANN (PTA)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:ANN
Last Name:TABATT-TAYLOR
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 20TH ST NW
Mailing Address - Street 2:
Mailing Address - City:EAST GRAND FORKS
Mailing Address - State:MN
Mailing Address - Zip Code:56721-1228
Mailing Address - Country:US
Mailing Address - Phone:701-740-3815
Mailing Address - Fax:
Practice Address - Street 1:600 20TH ST NW
Practice Address - Street 2:
Practice Address - City:EAST GRAND FORKS
Practice Address - State:MN
Practice Address - Zip Code:56721-1228
Practice Address - Country:US
Practice Address - Phone:701-740-3815
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA2187225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant