Healthcare Provider Details

I. General information

NPI: 1053697862
Provider Name (Legal Business Name): NICOLE MARIE POWELL DPT, ATC, LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2011
Last Update Date: 04/18/2024
Certification Date: 04/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 W BETHEL AVE
MUNCIE IN
47304-5407
US

IV. Provider business mailing address

2806 S MOCK AVE
MUNCIE IN
47302-5446
US

V. Phone/Fax

Practice location:
  • Phone: 765-213-3870
  • Fax:
Mailing address:
  • Phone: 260-729-7152
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number05010696A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number99048667A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number05010696A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: