Provider Demographics
NPI:1184092900
Name:RUNDE, NICOLE (COTA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:RUNDE
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3349 COUNTY ROAD H
Mailing Address - Street 2:
Mailing Address - City:CUBA CITY
Mailing Address - State:WI
Mailing Address - Zip Code:53807-9360
Mailing Address - Country:US
Mailing Address - Phone:608-568-3831
Mailing Address - Fax:
Practice Address - Street 1:1400 EASTSIDE RD
Practice Address - Street 2:
Practice Address - City:PLATTEVILLE
Practice Address - State:WI
Practice Address - Zip Code:53818-9800
Practice Address - Country:US
Practice Address - Phone:608-348-2331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-10
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1176224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant