Provider Demographics
NPI:1336301704
Name:NICHOLS, NICOLE (PT, DPT, ATC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:PT, DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1338 SOUTH EXTENSION ROAD
Mailing Address - Street 2:
Mailing Address - City:TOPINABEE
Mailing Address - State:MI
Mailing Address - Zip Code:49791
Mailing Address - Country:US
Mailing Address - Phone:231-818-0521
Mailing Address - Fax:
Practice Address - Street 1:1338 S EXTENSION ROAD
Practice Address - Street 2:
Practice Address - City:TOPINABEE
Practice Address - State:MI
Practice Address - Zip Code:49791
Practice Address - Country:US
Practice Address - Phone:231-818-0521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-27
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL1181086174400000X
NCPT13066225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist