Provider Demographics
NPI:1336524404
Name:NICKELL, JOSH
Entity Type:Individual
Prefix:
First Name:JOSH
Middle Name:
Last Name:NICKELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JOSHUA
Other - Middle Name:M
Other - Last Name:NICKELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT ASSISTANT
Mailing Address - Street 1:5005 BATES CREEK CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-2907
Mailing Address - Country:US
Mailing Address - Phone:573-881-9511
Mailing Address - Fax:
Practice Address - Street 1:3105 BLUFF CREEK DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-3529
Practice Address - Country:US
Practice Address - Phone:573-442-6060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-30
Last Update Date:2015-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant