Provider Demographics
NPI:1255705737
Name:BUSTA, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:BUSTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1439 295TH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT ATKINSON
Mailing Address - State:IA
Mailing Address - Zip Code:52144-7448
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:960 4TH ST NW
Practice Address - Street 2:
Practice Address - City:WAUKON
Practice Address - State:IA
Practice Address - Zip Code:52172-1059
Practice Address - Country:US
Practice Address - Phone:563-568-3493
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-20
Last Update Date:2015-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA078442235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist