Provider Demographics
NPI:1588260368
Name:HARRISON, NICOLE MARIE JOENS (ATC)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE JOENS
Last Name:HARRISON
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:MARIE
Other - Last Name:JOENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC
Mailing Address - Street 1:110 SOUTHSIDE DR
Mailing Address - Street 2:
Mailing Address - City:POCAHONTAS
Mailing Address - State:IA
Mailing Address - Zip Code:50574-2038
Mailing Address - Country:US
Mailing Address - Phone:712-212-5774
Mailing Address - Fax:
Practice Address - Street 1:110 SOUTHSIDE DR
Practice Address - Street 2:
Practice Address - City:POCAHONTAS
Practice Address - State:IA
Practice Address - Zip Code:50574-2038
Practice Address - Country:US
Practice Address - Phone:712-212-5774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-08
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTCA5942255A2300X
IA0971372255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer