Provider Demographics
NPI:1831475284
Name:NICOLELLO, TIMOTHY STEVEN (ATC)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:STEVEN
Last Name:NICOLELLO
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14078 W BUNKERHILL ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-0702
Mailing Address - Country:US
Mailing Address - Phone:208-874-3449
Mailing Address - Fax:
Practice Address - Street 1:1109 W MYRTLE ST
Practice Address - Street 2:SUITE 200
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6970
Practice Address - Country:US
Practice Address - Phone:208-874-3449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-31
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID246Z00000X
ID4002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other