Provider Demographics
NPI:1801228234
Name:FETT, NICOLE (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:
Last Name:FETT
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4560 SE INTERNATIONAL WAY
Mailing Address - Street 2:STE. 100
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222
Mailing Address - Country:US
Mailing Address - Phone:971-206-5200
Mailing Address - Fax:971-206-5203
Practice Address - Street 1:20 VILLAGE CIRCLE
Practice Address - Street 2:
Practice Address - City:KEOKUK
Practice Address - State:IA
Practice Address - Zip Code:52632
Practice Address - Country:US
Practice Address - Phone:319-524-5772
Practice Address - Fax:971-206-5203
Is Sole Proprietor?:No
Enumeration Date:2013-08-08
Last Update Date:2013-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA000807224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant