Provider Demographics
NPI:1669042362
Name:FORMENT, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:FORMENT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 HIGHWAY 17 N
Mailing Address - Street 2:
Mailing Address - City:BUTLER
Mailing Address - State:KY
Mailing Address - Zip Code:41006-8830
Mailing Address - Country:US
Mailing Address - Phone:859-669-6135
Mailing Address - Fax:
Practice Address - Street 1:2500 HIGHWAY 17 N
Practice Address - Street 2:
Practice Address - City:BUTLER
Practice Address - State:KY
Practice Address - Zip Code:41006-8830
Practice Address - Country:US
Practice Address - Phone:859-669-6135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-26
Last Update Date:2021-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor