Provider Demographics
NPI:1053697862
Name:POWELL, NICOLE MARIE (DPT, ATC, LAT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:POWELL
Suffix:
Gender:F
Credentials:DPT, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2806 S MOCK AVE
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47302-5446
Mailing Address - Country:US
Mailing Address - Phone:260-729-7152
Mailing Address - Fax:
Practice Address - Street 1:3600 W BETHEL AVE
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-5407
Practice Address - Country:US
Practice Address - Phone:765-213-3870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-25
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05010696A174400000X, 225100000X
IN99048667A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1103842746OtherANTHEM PTAN
IN300088469Medicaid