Provider Demographics
NPI:1457040164
Name:WILSON, NICOLE (COTA/L)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4254 CATALPA DR
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:KY
Mailing Address - Zip Code:41051-9516
Mailing Address - Country:US
Mailing Address - Phone:828-242-9025
Mailing Address - Fax:
Practice Address - Street 1:4250 GLENN AVE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:KY
Practice Address - Zip Code:41015-1641
Practice Address - Country:US
Practice Address - Phone:859-431-2244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-08
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY162043224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant