Provider Demographics
NPI:1730665308
Name:VIGE, NICOLE R (OT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:R
Last Name:VIGE
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:NIKI
Other - Middle Name:
Other - Last Name:KNERR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:961 BROKEN ARROW LN
Mailing Address - Street 2:
Mailing Address - City:CANTONMENT
Mailing Address - State:FL
Mailing Address - Zip Code:32533-3827
Mailing Address - Country:US
Mailing Address - Phone:831-238-0880
Mailing Address - Fax:
Practice Address - Street 1:4901 W FAIRFIELD DR
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32506-4111
Practice Address - Country:US
Practice Address - Phone:850-458-7735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-17
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL$$$$$$$$$Medicaid