Provider Demographics
NPI:1942967476
Name:LANDRUM, NICOLE S (COTA/L)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:S
Last Name:LANDRUM
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:921 SOMERSET AVE
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46544-4563
Mailing Address - Country:US
Mailing Address - Phone:702-517-0957
Mailing Address - Fax:
Practice Address - Street 1:333 W MISHAWAKA RD
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46517-1921
Practice Address - Country:US
Practice Address - Phone:574-293-1550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-18
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32003594A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant