Provider Demographics
NPI:1619338233
Name:NICHOLS, CARLA MARIE (PTA)
Entity type:Individual
Prefix:
First Name:CARLA
Middle Name:MARIE
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2806 YORKTOWN ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:NE
Mailing Address - Zip Code:68123-4489
Mailing Address - Country:US
Mailing Address - Phone:712-899-3373
Mailing Address - Fax:
Practice Address - Street 1:1313 S SADDLE CREEK RD
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68106-2402
Practice Address - Country:US
Practice Address - Phone:402-933-0100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-09
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2090801225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant