Provider Demographics
NPI:1912572637
Name:MARLEAU, NICHOLE ASHLEY (DPT)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:ASHLEY
Last Name:MARLEAU
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8382 N WAYNE DR STE 204
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-6028
Mailing Address - Country:US
Mailing Address - Phone:612-499-0001
Mailing Address - Fax:
Practice Address - Street 1:8382 N WAYNE DR STE 204
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-6028
Practice Address - Country:US
Practice Address - Phone:087-199-0712
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-25
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID7359225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist