Provider Demographics
NPI:1619306487
Name:NICHOLS, DIANN (PTA)
Entity Type:Individual
Prefix:
First Name:DIANN
Middle Name:
Last Name:NICHOLS
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 1:800 MAIN ST
Mailing Address - Street 2:STE 310
Mailing Address - City:ANDERSON
Mailing Address - State:IN
Mailing Address - Zip Code:46016-1559
Mailing Address - Country:US
Mailing Address - Phone:765-644-0500
Mailing Address - Fax:765-644-0510
Practice Address - Street 1:800 MAIN ST
Practice Address - Street 2:STE 310
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46016-1559
Practice Address - Country:US
Practice Address - Phone:765-644-0500
Practice Address - Fax:765-644-0510
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-02
Last Update Date:2013-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06004656A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant