MEDICARE: NICOLE NOVOTNY PT

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	2026	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	NM00Q517	OTHER	NM	BCBS NM

General Provider Information

NPI Number	:	1801884416
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE NOVOTNY PT

Provider Business Mailing Address
First Line	:	2455 MISSOURI AVE
Second Line	:	SUITE B
City	:	LAS CRUCES
State	:	NM
Zip	:	88001-5122
Country	:	US
Telephone Number	:	575-556-8440
Fax Number	:	575-556-8439

Provider Business Practice Location Address
First Line	:	2455 MISSOURI AVE
Second Line	:	SUITE B
City	:	LAS CRUCES
State	:	NM
Zip	:	88001-5122
Country	:	US
Telephone Number	:	575-556-8440
Fax Number	:	575-556-8439

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

Provider Enumeration Date	:	10/07/2005
Last Update Date	:	04/29/2015

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Directions to “ NICOLE NOVOTNY PT” Practice Location

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