Provider Demographics
NPI:1750977617
Name:MONAHAN, NICOLE (PTA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MONAHAN
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 1:3691 WILLOWCREEK RD STE 100
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-5000
Mailing Address - Country:US
Mailing Address - Phone:219-759-4380
Mailing Address - Fax:219-759-1989
Practice Address - Street 1:3691 WILLOWCREEK RD STE 100
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-5000
Practice Address - Country:US
Practice Address - Phone:219-759-4380
Practice Address - Fax:219-759-1989
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-15
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN06006164AOtherPTA