Provider Demographics
NPI:1740815133
Name:LEMERY, NICOLE MICHELLE (PTA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MICHELLE
Last Name:LEMERY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W5607 WILLOW ROAD NUMBER 3.5
Mailing Address - Street 2:
Mailing Address - City:MENOMINEE
Mailing Address - State:MI
Mailing Address - Zip Code:49858-9101
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:831 PINE BEACH RD
Practice Address - Street 2:
Practice Address - City:MARINETTE
Practice Address - State:WI
Practice Address - Zip Code:54143-4225
Practice Address - Country:US
Practice Address - Phone:715-732-0155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-06
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2776-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant