Provider Demographics
NPI:1205203551
Name:EASTES, NICOLE MARIE (PHD, ATC, LAT)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:MARIE
Last Name:EASTES
Suffix:
Gender:F
Credentials:PHD, ATC, LAT
Other - Prefix:DR
Other - First Name:NICOLE
Other - Middle Name:MARIE
Other - Last Name:GLASGOW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD, LAT, ATC
Mailing Address - Street 1:1105 SUNSET AVE
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66502-3739
Mailing Address - Country:US
Mailing Address - Phone:810-580-9139
Mailing Address - Fax:
Practice Address - Street 1:1105 SUNSET AVE
Practice Address - Street 2:
Practice Address - City:MANHATTAN
Practice Address - State:KS
Practice Address - Zip Code:66502-3739
Practice Address - Country:US
Practice Address - Phone:810-580-9139
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-21
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
KS24-008322255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer