Healthcare Provider Details

I. General information

NPI: 1053796177
Provider Name (Legal Business Name): NICHOLE SCHLAKE PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2015
Last Update Date: 07/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 H ST
FAIRBURY NE
68352-1119
US

IV. Provider business mailing address

PO BOX 277
FAIRBURY NE
68352-0277
US

V. Phone/Fax

Practice location:
  • Phone: 402-729-6840
  • Fax:
Mailing address:
  • Phone: 402-729-6840
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number3509
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: