Provider Demographics
NPI:1821565938
Name:TOMBERS, NICOLE A (PTA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:A
Last Name:TOMBERS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 COVENTRY WAY
Mailing Address - Street 2:
Mailing Address - City:NOBLESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46062-9027
Mailing Address - Country:US
Mailing Address - Phone:317-918-4423
Mailing Address - Fax:
Practice Address - Street 1:970 W JUNIPER AVE
Practice Address - Street 2:
Practice Address - City:HERMISTON
Practice Address - State:OR
Practice Address - Zip Code:97838-2118
Practice Address - Country:US
Practice Address - Phone:541-567-8337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-26
Last Update Date:2018-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP160883463225200000X
OK09669225200000X
IN060095760A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant