Provider Demographics
NPI:1821449158
Name:BURGE, NICOLE (DPT, ATC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:BURGE
Suffix:
Gender:F
Credentials:DPT, ATC
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:CRITCHFIELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3497
Mailing Address - Street 2:
Mailing Address - City:STURTEVANT
Mailing Address - State:WI
Mailing Address - Zip Code:53177-0300
Mailing Address - Country:US
Mailing Address - Phone:877-552-2996
Mailing Address - Fax:866-245-8064
Practice Address - Street 1:1213 N BELT HWY
Practice Address - Street 2:SUITE H
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-2411
Practice Address - Country:US
Practice Address - Phone:816-279-7778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-28
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016021895225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOX90000006Medicare PIN