Provider Demographics
NPI:1598963720
Name:NICKELS, SUZANNE M (PTA)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:M
Last Name:NICKELS
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 1:723 SAINT JOSEPH RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63129-7107
Mailing Address - Country:US
Mailing Address - Phone:314-845-0332
Mailing Address - Fax:
Practice Address - Street 1:12509 VILLAGE CIRCLE DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63127-1701
Practice Address - Country:US
Practice Address - Phone:314-270-7790
Practice Address - Fax:314-849-2045
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-10
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO116415225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant