Provider Demographics
NPI:1932795804
Name:EASTMAN, NICHOLE
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:
Last Name:EASTMAN
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 1:1905 W 57TH ST ST 3
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108
Mailing Address - Country:US
Mailing Address - Phone:605-371-3533
Mailing Address - Fax:605-371-1781
Practice Address - Street 1:1905 W 57TH ST ST 3
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108
Practice Address - Country:US
Practice Address - Phone:605-371-3533
Practice Address - Fax:605-371-1798
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-15
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDMT11055225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD11055OtherNON MEDICARE PROVIDER