Provider Demographics
NPI:1992185490
Name:COONES, NICKOLAS
Entity Type:Individual
Prefix:
First Name:NICKOLAS
Middle Name:
Last Name:COONES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 195
Mailing Address - Street 2:
Mailing Address - City:GENTRY
Mailing Address - State:AR
Mailing Address - Zip Code:72734-0195
Mailing Address - Country:US
Mailing Address - Phone:479-640-3404
Mailing Address - Fax:
Practice Address - Street 1:201 S GILES AVE
Practice Address - Street 2:
Practice Address - City:GENTRY
Practice Address - State:AR
Practice Address - Zip Code:72734-9320
Practice Address - Country:US
Practice Address - Phone:479-736-8562
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-01
Last Update Date:2015-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROT-A973224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant