Provider Demographics
NPI:1972760080
Name:NUCKOLS, DONNA JEAN (PTA)
Entity type:Individual
Prefix:MRS
First Name:DONNA
Middle Name:JEAN
Last Name:NUCKOLS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3430 W. 600 S.
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:IN
Mailing Address - Zip Code:47371
Mailing Address - Country:US
Mailing Address - Phone:260-726-5750
Mailing Address - Fax:
Practice Address - Street 1:1800 N WABASH RD
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-1300
Practice Address - Country:US
Practice Address - Phone:765-651-3229
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-18
Last Update Date:2008-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06002184A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant