Provider Demographics
NPI:1679879811
Name:NICOL, ANNIE TANIS (LMT)
Entity Type:Individual
Prefix:
First Name:ANNIE
Middle Name:TANIS
Last Name:NICOL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 S 3RD ST W
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-2729
Mailing Address - Country:US
Mailing Address - Phone:406-207-6486
Mailing Address - Fax:
Practice Address - Street 1:141 S 3RD ST W
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-2729
Practice Address - Country:US
Practice Address - Phone:406-207-6486
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-06
Last Update Date:2011-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1015225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist