Provider Demographics
NPI:1760664783
Name:KOENIGSHOF, NICOLE NICHELLE (MSPT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:NICHELLE
Last Name:KOENIGSHOF
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4251 LAHMEYER RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-5676
Mailing Address - Country:US
Mailing Address - Phone:260-482-7800
Mailing Address - Fax:260-484-0273
Practice Address - Street 1:624 W LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-2416
Practice Address - Country:US
Practice Address - Phone:574-931-2801
Practice Address - Fax:574-971-8569
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-30
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05011693A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist