Provider Demographics
NPI:1780127217
Name:PHELPS, NICOLE (COTA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:PHELPS
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 N JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:KNIGHTSTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:46148-1024
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:420 N JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:KNIGHTSTOWN
Practice Address - State:IN
Practice Address - Zip Code:46148-1024
Practice Address - Country:US
Practice Address - Phone:317-494-0233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-01
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32002561A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN32002561AMedicare PIN