Provider Demographics
NPI:1053935866
Name:WIGGINS, NICOLE RENE (OTR, MOT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:RENE
Last Name:WIGGINS
Suffix:
Gender:F
Credentials:OTR, MOT
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:RENE
Other - Last Name:OVERMEYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6325 VILLA ROSA WAY
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75707-1406
Mailing Address - Country:US
Mailing Address - Phone:903-312-1873
Mailing Address - Fax:
Practice Address - Street 1:401 E FRONT ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-8213
Practice Address - Country:US
Practice Address - Phone:903-531-2581
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-08
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX120512225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist