Provider Demographics
NPI:1861007577
Name:HOLTAM, NICOLE MARIE (PTA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:HOLTAM
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 1:1235 N 206TH ST
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:NE
Mailing Address - Zip Code:68022-6914
Mailing Address - Country:US
Mailing Address - Phone:402-212-7632
Mailing Address - Fax:
Practice Address - Street 1:1010 LONGVIEW RD
Practice Address - Street 2:
Practice Address - City:MISSOURI VALLEY
Practice Address - State:IA
Practice Address - Zip Code:51555-1227
Practice Address - Country:US
Practice Address - Phone:503-788-7224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-10
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1606225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant