Healthcare Provider Details

I. General information

NPI: 1487643532
Provider Name (Legal Business Name): NICOLE ANN RICHARDSON
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: NICOLE ANN MARSHALL

II. Dates (important events)

Enumeration Date: 10/20/2005
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIT 6180 BOX 245
APO AE
09604
US

IV. Provider business mailing address

PSC 54 BOX 2808
APO AE
09601
US

V. Phone/Fax

Practice location:
  • Phone: 43-430-5459
  • Fax: 43-430-5413
Mailing address:
  • Phone: 43-459-0813
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT 12028
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: