Healthcare Provider Details

I. General information

NPI: 1770088726
Provider Name (Legal Business Name): NICOLE CHADWICK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2018
Last Update Date: 04/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

146 RECREATION BLDG
UNIVERSITY PARK PA
16802-5700
US

IV. Provider business mailing address

33 WHICHITA RD
MEDFIELD MA
02052-2932
US

V. Phone/Fax

Practice location:
  • Phone: 814-865-7936
  • Fax:
Mailing address:
  • Phone: 508-596-2464
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: