Provider Demographics
NPI:1487643532
Name:RICHARDSON, NICOLE ANN
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:ANN
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:ANN
Other - Last Name:MARSHALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PSC 54 BOX 2808
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09601
Mailing Address - Country:US
Mailing Address - Phone:043-459-0813
Mailing Address - Fax:
Practice Address - Street 1:UNIT 6180 BOX 245
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09604
Practice Address - Country:US
Practice Address - Phone:043-430-5459
Practice Address - Fax:043-430-5413
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-20
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT 12028225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics