Provider Demographics
NPI:1154402485
Name:KENYON, NICOLE IRENE (PT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:IRENE
Last Name:KENYON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:IRENE
Other - Last Name:MEHRWERTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:911 NORTHLAND DR.
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:MN
Mailing Address - Zip Code:55371
Mailing Address - Country:US
Mailing Address - Phone:763-389-6513
Mailing Address - Fax:763-389-6410
Practice Address - Street 1:911 NORTHLAND DR.
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:MN
Practice Address - Zip Code:55371
Practice Address - Country:US
Practice Address - Phone:763-389-6513
Practice Address - Fax:763-389-6410
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7436225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist