Provider Demographics
NPI:1811958986
Name:SUMMERS, NICOLE (ATC)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:SUMMERS
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 GRIM PL
Mailing Address - Street 2:
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63501-4438
Mailing Address - Country:US
Mailing Address - Phone:660-341-6056
Mailing Address - Fax:
Practice Address - Street 1:800 W JEFFERSON
Practice Address - Street 2:NORTHEAST REGIONAL MEDICAL CENTER
Practice Address - City:KIRKSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63501
Practice Address - Country:US
Practice Address - Phone:660-785-1834
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-29
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20030163752255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer