Healthcare Provider Details

I. General information

NPI: 1730665308
Provider Name (Legal Business Name): NICOLE R VIGE OT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: NIKI KNERR

II. Dates (important events)

Enumeration Date: 07/17/2018
Last Update Date: 07/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4901 W FAIRFIELD DR
PENSACOLA FL
32506-4111
US

IV. Provider business mailing address

961 BROKEN ARROW LN
CANTONMENT FL
32533-3827
US

V. Phone/Fax

Practice location:
  • Phone: 850-458-7735
  • Fax:
Mailing address:
  • Phone: 831-238-0880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: