Healthcare Provider Details

I. General information

NPI: 1629244017
Provider Name (Legal Business Name): NIKKI POOLE PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2008
Last Update Date: 05/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9909 E 100 S
GREENTOWN IN
46936-9163
US

IV. Provider business mailing address

9909 E 100 S
GREENTOWN IN
46936-9163
US

V. Phone/Fax

Practice location:
  • Phone: 765-628-0605
  • Fax: 765-628-3639
Mailing address:
  • Phone: 765-628-0605
  • Fax: 765-628-3639

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number06001474
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: