Provider Demographics
NPI:1982368304
Name:SMITH, NICOLE MARIE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:SMITH
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 1:1807 ELDORADO DR
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:CO
Mailing Address - Zip Code:80027-8256
Mailing Address - Country:US
Mailing Address - Phone:303-513-8832
Mailing Address - Fax:
Practice Address - Street 1:1807 ELDORADO DR
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:CO
Practice Address - Zip Code:80027-8256
Practice Address - Country:US
Practice Address - Phone:303-513-8832
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-22
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0014441225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant