Provider Demographics
NPI:1528264264
Name:MEREDITH, NIKOLE EMBER (OTR)
Entity type:Individual
Prefix:MRS
First Name:NIKOLE
Middle Name:EMBER
Last Name:MEREDITH
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4091 W ERIN DR
Mailing Address - Street 2:
Mailing Address - City:LA PORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46350-7456
Mailing Address - Country:US
Mailing Address - Phone:219-324-0390
Mailing Address - Fax:
Practice Address - Street 1:220 DUNES PLZ
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-7340
Practice Address - Country:US
Practice Address - Phone:219-874-3750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31003145A174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist