Provider Demographics
NPI:1699488593
Name:SEALS, NICOLE (LAC)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:SEALS
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4107 MEDICAL PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78756-3736
Mailing Address - Country:US
Mailing Address - Phone:737-217-6404
Mailing Address - Fax:
Practice Address - Street 1:4107 MEDICAL PKWY STE 100
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78756-3736
Practice Address - Country:US
Practice Address - Phone:737-217-6404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-05
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAC02084171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAC02084OtherTEXAS MEDICAL BOARD