MEDICARE: NICOLE L BACK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1598544561
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE L BACK

Provider Business Mailing Address
First Line	:	4220 HOUSTON RD
Second Line	:
City	:	ERLANGER
State	:	KY
Zip	:	41018-3402
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4220 HOUSTON RD
Second Line	:
City	:	ERLANGER
State	:	KY
Zip	:	41018-3402
Country	:	US
Telephone Number	:	859-727-6700
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/27/2023
Last Update Date	:	09/27/2023

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Directions to “ NICOLE L BACK ” Practice Location

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