Provider Demographics
NPI:1801884416
Name:NOVOTNY, NICOLE (PT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:NOVOTNY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2455 MISSOURI AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-5122
Mailing Address - Country:US
Mailing Address - Phone:575-556-8440
Mailing Address - Fax:575-556-8439
Practice Address - Street 1:2455 MISSOURI AVE
Practice Address - Street 2:SUITE B
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-5122
Practice Address - Country:US
Practice Address - Phone:575-556-8440
Practice Address - Fax:575-556-8439
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2026225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM87750066Medicaid
NMNM00Q517OtherBCBS NM
NM87750066Medicaid