Provider Demographics
NPI:1184794810
Name:NICHOLS, JUDIANNE KING (MPT)
Entity type:Individual
Prefix:MRS
First Name:JUDIANNE
Middle Name:KING
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9652 W STATE STREET
Mailing Address - Street 2:
Mailing Address - City:STAR
Mailing Address - State:ID
Mailing Address - Zip Code:83669-5858
Mailing Address - Country:US
Mailing Address - Phone:208-286-0766
Mailing Address - Fax:208-286-0768
Practice Address - Street 1:9652 W STATE STREET
Practice Address - Street 2:
Practice Address - City:STAR
Practice Address - State:ID
Practice Address - Zip Code:83669-5858
Practice Address - Country:US
Practice Address - Phone:208-286-0766
Practice Address - Fax:208-286-0768
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2012-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1371225100000X
IDRPT1371225100000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806941800Medicaid
1655427Medicare PIN