Provider Demographics
NPI:1063195436
Name:PRYOR, NICOLE (LMT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:PRYOR
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 RIVER RUN CT
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40324-8444
Mailing Address - Country:US
Mailing Address - Phone:859-904-3134
Mailing Address - Fax:
Practice Address - Street 1:2716 OLD ROSEBUD RD STE 230
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-8003
Practice Address - Country:US
Practice Address - Phone:859-263-8833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-10
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY104962225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist