Provider Demographics
NPI:1316102957
Name:OUELLETTE, NICKY (LMT)
Entity type:Individual
Prefix:
First Name:NICKY
Middle Name:
Last Name:OUELLETTE
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 1:89 LARRABEE RD
Mailing Address - Street 2:
Mailing Address - City:WESTBROOK
Mailing Address - State:ME
Mailing Address - Zip Code:04092-4744
Mailing Address - Country:US
Mailing Address - Phone:207-854-2001
Mailing Address - Fax:207-854-2004
Practice Address - Street 1:89 LARRABEE RD
Practice Address - Street 2:
Practice Address - City:WESTBROOK
Practice Address - State:ME
Practice Address - Zip Code:04092-4744
Practice Address - Country:US
Practice Address - Phone:207-854-2001
Practice Address - Fax:207-854-2004
Is Sole Proprietor?:No
Enumeration Date:2008-07-23
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMT3405225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist