Provider Demographics
NPI:1962775890
Name:PALKO, NICOLE MARIE (IDMT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:PALKO
Suffix:
Gender:F
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 MDG UNIT 3690
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09126
Mailing Address - Country:US
Mailing Address - Phone:570-245-5659
Mailing Address - Fax:
Practice Address - Street 1:UNIT 3690 BOX MDG
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09126-3690
Practice Address - Country:US
Practice Address - Phone:570-245-5659
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-23
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
19627758901710I1003X
1710I1003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians