Provider Demographics
NPI:1811420318
Name:NICKOLAUS, KRYSTN (PT)
Entity Type:Individual
Prefix:DR
First Name:KRYSTN
Middle Name:
Last Name:NICKOLAUS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10000 W 75TH ST
Mailing Address - Street 2:SUITE 250
Mailing Address - City:MERRIAM
Mailing Address - State:KS
Mailing Address - Zip Code:66204-2209
Mailing Address - Country:US
Mailing Address - Phone:888-913-1910
Mailing Address - Fax:877-913-1174
Practice Address - Street 1:10000 W 75TH ST
Practice Address - Street 2:SUITE 250
Practice Address - City:MERRIAM
Practice Address - State:KS
Practice Address - Zip Code:66204-2209
Practice Address - Country:US
Practice Address - Phone:888-913-1910
Practice Address - Fax:877-913-1174
Is Sole Proprietor?:No
Enumeration Date:2017-04-11
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016028624225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist