Provider Demographics
NPI:1053048074
Name:MYERS, NICOLE (PTA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MYERS
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 1:60 TIMBERCREST CIR
Mailing Address - Street 2:
Mailing Address - City:HILTON HEAD ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29926-2058
Mailing Address - Country:US
Mailing Address - Phone:845-464-2087
Mailing Address - Fax:
Practice Address - Street 1:60 N MAIN ST UNIT G
Practice Address - Street 2:
Practice Address - City:HILTON HEAD ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29926-6603
Practice Address - Country:US
Practice Address - Phone:843-715-4146
Practice Address - Fax:843-715-4673
Is Sole Proprietor?:No
Enumeration Date:2022-08-02
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4938225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant