Provider Demographics
NPI:1831978030
Name:VINE-BRAUN, NICOLE PATRICE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:PATRICE
Last Name:VINE-BRAUN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:PATRICE
Other - Last Name:BRAUN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OTR
Mailing Address - Street 1:33927 PRAIRIE EDGE DR
Mailing Address - Street 2:
Mailing Address - City:NEW CARLISLE
Mailing Address - State:IN
Mailing Address - Zip Code:46552-8253
Mailing Address - Country:US
Mailing Address - Phone:317-408-2020
Mailing Address - Fax:
Practice Address - Street 1:31869 CHICAGO TRL
Practice Address - Street 2:
Practice Address - City:NEW CARLISLE
Practice Address - State:IN
Practice Address - Zip Code:46552-9639
Practice Address - Country:US
Practice Address - Phone:574-654-2266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-26
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31003762A225XN1300X, 225XE0001X, 225XG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XG0600XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGerontology
No225XN1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistNeurorehabilitation
No225XE0001XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistEnvironmental Modification