Provider Demographics
NPI:1952601015
Name:PHILLIP, NIKOLA LEONORA (ATC)
Entity Type:Individual
Prefix:MISS
First Name:NIKOLA
Middle Name:LEONORA
Last Name:PHILLIP
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2140 JOHNSTON DR APT 5
Mailing Address - Street 2:
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18020-3386
Mailing Address - Country:US
Mailing Address - Phone:484-661-3626
Mailing Address - Fax:
Practice Address - Street 1:3835 GREEN POND RD
Practice Address - Street 2:
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18020-7568
Practice Address - Country:US
Practice Address - Phone:610-332-8692
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-22
Last Update Date:2010-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART0048732255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer