Provider Demographics
NPI:1184957524
Name:BAKER, NICHOLE (PTA)
Entity type:Individual
Prefix:
First Name:NICHOLE
Middle Name:
Last Name:BAKER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:821 S 7TH ST
Mailing Address - Street 2:
Mailing Address - City:LANDER
Mailing Address - State:WY
Mailing Address - Zip Code:82520-3603
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8204 HIGHWAY 789
Practice Address - Street 2:
Practice Address - City:LANDER
Practice Address - State:WY
Practice Address - Zip Code:82520-2941
Practice Address - Country:US
Practice Address - Phone:307-335-6731
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-17
Last Update Date:2009-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPTA-0422225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant