Provider Demographics
NPI:1699231977
Name:NICHOLSON, EMILY YVONNE (ATC, LAT)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:YVONNE
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 THORNTON AVE # 101
Mailing Address - Street 2:
Mailing Address - City:SACO
Mailing Address - State:ME
Mailing Address - Zip Code:04072-2891
Mailing Address - Country:US
Mailing Address - Phone:207-294-8448
Mailing Address - Fax:
Practice Address - Street 1:88 WEST RD
Practice Address - Street 2:
Practice Address - City:WATERBORO
Practice Address - State:ME
Practice Address - Zip Code:04087-3209
Practice Address - Country:US
Practice Address - Phone:207-247-3141
Practice Address - Fax:207-247-3146
Is Sole Proprietor?:No
Enumeration Date:2019-02-12
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAT6932081S0010X, 2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine