Provider Demographics
NPI:1629244017
Name:POOLE, NIKKI (PTA)
Entity Type:Individual
Prefix:
First Name:NIKKI
Middle Name:
Last Name:POOLE
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 1:9909 E 100 S
Mailing Address - Street 2:
Mailing Address - City:GREENTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:46936-9163
Mailing Address - Country:US
Mailing Address - Phone:765-628-0605
Mailing Address - Fax:765-628-3639
Practice Address - Street 1:9909 E 100 S
Practice Address - Street 2:
Practice Address - City:GREENTOWN
Practice Address - State:IN
Practice Address - Zip Code:46936-9163
Practice Address - Country:US
Practice Address - Phone:765-628-0605
Practice Address - Fax:765-628-3639
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-05
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN060014742251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200844350Medicaid