Provider Demographics
NPI:1760091250
Name:WILLSE, NICOLE (OTD, OTR/L)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:WILLSE
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1915 PHILADELPHIA ST
Mailing Address - Street 2:
Mailing Address - City:AMES
Mailing Address - State:IA
Mailing Address - Zip Code:50010-8768
Mailing Address - Country:US
Mailing Address - Phone:515-232-7220
Mailing Address - Fax:515-232-3834
Practice Address - Street 1:1915 PHILADELPHIA ST
Practice Address - Street 2:
Practice Address - City:AMES
Practice Address - State:IA
Practice Address - Zip Code:50010-8768
Practice Address - Country:US
Practice Address - Phone:515-232-7220
Practice Address - Fax:515-727-8757
Is Sole Proprietor?:No
Enumeration Date:2020-07-30
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA101811225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist