Provider Demographics
NPI:1821389495
Name:NICKEL, CAROL ANN (PT)
Entity type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:ANN
Last Name:NICKEL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:CAROL
Other - Middle Name:ANN
Other - Last Name:KANTMANN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:5484 CANVASBACK ROAD
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:WA
Mailing Address - Zip Code:98230
Mailing Address - Country:US
Mailing Address - Phone:360-371-3148
Mailing Address - Fax:
Practice Address - Street 1:315 MAIN ST
Practice Address - Street 2:VALLEY KIDS THERAPY
Practice Address - City:MT. VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-2314
Practice Address - Country:US
Practice Address - Phone:360-336-3432
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-29
Last Update Date:2011-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00009559225100000X
CAPT1714225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist