Healthcare Provider Details

I. General information

NPI: 1821554064
Provider Name (Legal Business Name): NICOLE ANN MACKE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2019
Last Update Date: 02/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7811 LOCUST LN
CINCINNATI OH
45243-1909
US

IV. Provider business mailing address

7811 LOCUST LN
CINCINNATI OH
45243-1909
US

V. Phone/Fax

Practice location:
  • Phone: 513-235-1035
  • Fax:
Mailing address:
  • Phone: 513-235-1035
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: