Provider Demographics
NPI:1144485509
Name:SHOUP, NICOLE RAE (DPT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:RAE
Last Name:SHOUP
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:RAE
Other - Last Name:ELLIOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:810 E 23RD ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-2135
Mailing Address - Country:US
Mailing Address - Phone:605-331-5890
Mailing Address - Fax:
Practice Address - Street 1:810 E 23RD ST
Practice Address - Street 2:SUITE 101
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-2135
Practice Address - Country:US
Practice Address - Phone:605-331-5890
Practice Address - Fax:605-336-3974
Is Sole Proprietor?:No
Enumeration Date:2008-07-25
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO10088225100000X
MO2012030396225100000X
SD1810225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC477678Medicare PIN