Provider Demographics
NPI:1770113532
Name:AUGUSTUS, NICOLE RACHELLE (LMT, STNA, CMA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:RACHELLE
Last Name:AUGUSTUS
Suffix:
Gender:F
Credentials:LMT, STNA, CMA
Other - Prefix:
Other - First Name:NYKI
Other - Middle Name:
Other - Last Name:AUGUSTUS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMT, STNA, CMA
Mailing Address - Street 1:920 E SANDUSKY AVE
Mailing Address - Street 2:
Mailing Address - City:BELLEFONTAINE
Mailing Address - State:OH
Mailing Address - Zip Code:43311-2856
Mailing Address - Country:US
Mailing Address - Phone:937-404-1214
Mailing Address - Fax:
Practice Address - Street 1:920 E SANDUSKY AVE
Practice Address - Street 2:
Practice Address - City:BELLEFONTAINE
Practice Address - State:OH
Practice Address - Zip Code:43311-2856
Practice Address - Country:US
Practice Address - Phone:937-404-1214
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-21
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172M00000X
OH401336661211376K00000X
OH33.023584225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No172M00000XOther Service ProvidersMechanotherapist
No376K00000XNursing Service Related ProvidersNurse's Aide