Provider Demographics
NPI:1770079147
Name:OLDFATHER, NICOLE L (PTA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:L
Last Name:OLDFATHER
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 1:965 W RYAN RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46725-8402
Mailing Address - Country:US
Mailing Address - Phone:260-229-3089
Mailing Address - Fax:
Practice Address - Street 1:702 N SAWYER RD
Practice Address - Street 2:
Practice Address - City:KENDALLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46755-2532
Practice Address - Country:US
Practice Address - Phone:260-347-3333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-09
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06002493A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant