Provider Demographics
NPI:1285114702
Name:NICELY, DEVON (PTA)
Entity type:Individual
Prefix:
First Name:DEVON
Middle Name:
Last Name:NICELY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:877 WIND FOREST DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGBORO
Mailing Address - State:OH
Mailing Address - Zip Code:45066-9016
Mailing Address - Country:US
Mailing Address - Phone:193-775-0024
Mailing Address - Fax:
Practice Address - Street 1:1920 BARNEY RD
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:CA
Practice Address - Zip Code:96007-4337
Practice Address - Country:US
Practice Address - Phone:193-775-0024
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-14
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant