Provider Demographics
NPI:1831541184
Name:MENIETTTI, NICHOLAS (ATC)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:MENIETTTI
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1725 UNIVERSITY AVE S
Mailing Address - Street 2:APT D45
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-4932
Mailing Address - Country:US
Mailing Address - Phone:618-972-0274
Mailing Address - Fax:
Practice Address - Street 1:1725 UNIVERSITY AVE S
Practice Address - Street 2:APT D45
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-4932
Practice Address - Country:US
Practice Address - Phone:618-972-0274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-11
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0960036962255A2300X
PARTO0001742255A2300X
AK1160522255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer