Provider Demographics
NPI:1891418364
Name:WALETZKI, NICOLE ANNE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ANNE
Last Name:WALETZKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2991 STUNNING DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE ELM
Mailing Address - State:TX
Mailing Address - Zip Code:75068-4004
Mailing Address - Country:US
Mailing Address - Phone:571-225-1809
Mailing Address - Fax:
Practice Address - Street 1:2900 S VALLEY PKWY
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75067-2077
Practice Address - Country:US
Practice Address - Phone:972-829-2111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-20
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT81522255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer