Provider Demographics
NPI:1770949463
Name:STEWART, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:STEWART
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:NICOLE
Other - Middle Name:MARIE
Other - Last Name:MCKENZIE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PTA
Mailing Address - Street 1:257 CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:MOGADORE
Mailing Address - State:OH
Mailing Address - Zip Code:44260-1549
Mailing Address - Country:US
Mailing Address - Phone:330-688-1188
Mailing Address - Fax:330-688-1278
Practice Address - Street 1:2910 LERMITAGE PL
Practice Address - Street 2:
Practice Address - City:STOW
Practice Address - State:OH
Practice Address - Zip Code:44224-5219
Practice Address - Country:US
Practice Address - Phone:330-688-1188
Practice Address - Fax:330-688-1278
Is Sole Proprietor?:No
Enumeration Date:2016-01-11
Last Update Date:2016-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA.02837225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant