Provider Demographics
NPI:1740730811
Name:WILSON, NICHOLE CHAUNTELLE
Entity type:Individual
Prefix:
First Name:NICHOLE
Middle Name:CHAUNTELLE
Last Name:WILSON
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 1:150 SHOUP AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-3657
Mailing Address - Country:US
Mailing Address - Phone:208-359-4778
Mailing Address - Fax:
Practice Address - Street 1:150 SHOUP AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-3657
Practice Address - Country:US
Practice Address - Phone:208-359-4778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-12
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist