Healthcare Provider Details

I. General information

NPI: 1619884186
Provider Name (Legal Business Name): NICOLE LEE WALLACE PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: NICOLE LEE WOOLBRIGHT

II. Dates (important events)

Enumeration Date: 08/27/2026
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1531 E BRADFORD PKWY STE 210-4
SPRINGFIELD MO
65804-6539
US

IV. Provider business mailing address

1531 E BRADFORD PKWY STE 210-4
SPRINGFIELD MO
65804-6539
US

V. Phone/Fax

Practice location:
  • Phone: 417-881-9500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2025036692
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: