Provider Demographics
NPI:1689266116
Name:ROEDEL, NICHOLE
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:
Last Name:ROEDEL
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 1:11771 MIRA LAGO BLVD APT 1134
Mailing Address - Street 2:
Mailing Address - City:FARMERS BRANCH
Mailing Address - State:TX
Mailing Address - Zip Code:75234-6470
Mailing Address - Country:US
Mailing Address - Phone:952-270-5059
Mailing Address - Fax:
Practice Address - Street 1:61 N KEGLEY RD
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76502-4067
Practice Address - Country:US
Practice Address - Phone:254-899-2225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-05
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14682111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor