Provider Demographics
NPI:1538443858
Name:EDMONDS, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:EDMONDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 N UNION ST
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46901-2907
Mailing Address - Country:US
Mailing Address - Phone:765-454-9748
Mailing Address - Fax:765-450-6664
Practice Address - Street 1:625 N UNION ST
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46901-2907
Practice Address - Country:US
Practice Address - Phone:765-454-9748
Practice Address - Fax:765-450-6664
Is Sole Proprietor?:No
Enumeration Date:2011-10-05
Last Update Date:2017-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT.013455225100000X
IN05010790225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist