Provider Demographics
NPI:1922452259
Name:TRUMBO, NICOLE LAUREN (COTA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LAUREN
Last Name:TRUMBO
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:LAUREN
Other - Last Name:HAGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 876104
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99687-6104
Mailing Address - Country:US
Mailing Address - Phone:907-982-3897
Mailing Address - Fax:
Practice Address - Street 1:619 S KNIK GOOSE BAY RD
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-8075
Practice Address - Country:US
Practice Address - Phone:907-982-3897
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-22
Last Update Date:2016-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3511224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant