Provider Demographics
NPI:1932481157
Name:TULLY, NICOLE (OTR)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:TULLY
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:ROEBLING
Mailing Address - State:NJ
Mailing Address - Zip Code:08554-1001
Mailing Address - Country:US
Mailing Address - Phone:609-440-7097
Mailing Address - Fax:
Practice Address - Street 1:902 JACKSONVILLE RD
Practice Address - Street 2:
Practice Address - City:BURLINGTON TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:08016-3814
Practice Address - Country:US
Practice Address - Phone:609-239-3894
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-14
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR00567000225X00000X
PAOC012017225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist