Provider Demographics
NPI:1053532242
Name:CUSTER, NICOLE LEE (OTRL)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:LEE
Last Name:CUSTER
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:LEE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTRL
Mailing Address - Street 1:2113 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:CAMP HILL
Mailing Address - State:PA
Mailing Address - Zip Code:17011-5454
Mailing Address - Country:US
Mailing Address - Phone:717-571-2776
Mailing Address - Fax:
Practice Address - Street 1:2113 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:CAMP HILL
Practice Address - State:PA
Practice Address - Zip Code:17011-5454
Practice Address - Country:US
Practice Address - Phone:717-571-2776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC009193174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist