Provider Demographics
NPI:1891275186
Name:HAINES, NICOLE MADISEN
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MADISEN
Last Name:HAINES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12174 DARBY CREEK DR
Mailing Address - Street 2:
Mailing Address - City:EAST LIBERTY
Mailing Address - State:OH
Mailing Address - Zip Code:43319-9469
Mailing Address - Country:US
Mailing Address - Phone:419-560-9728
Mailing Address - Fax:
Practice Address - Street 1:4787 TREMONT CLUB DR
Practice Address - Street 2:
Practice Address - City:HILLIARD
Practice Address - State:OH
Practice Address - Zip Code:43026-5034
Practice Address - Country:US
Practice Address - Phone:614-777-6001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-16
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOTA007327224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant