Provider Demographics
NPI:1992583439
Name:BANDSTRA, NICOLE RAE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:RAE
Last Name:BANDSTRA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 126
Mailing Address - Street 2:
Mailing Address - City:NEW SHARON
Mailing Address - State:IA
Mailing Address - Zip Code:50207-0126
Mailing Address - Country:US
Mailing Address - Phone:641-278-5005
Mailing Address - Fax:
Practice Address - Street 1:110 E 10TH ST
Practice Address - Street 2:
Practice Address - City:PELLA
Practice Address - State:IA
Practice Address - Zip Code:50219-2002
Practice Address - Country:US
Practice Address - Phone:641-278-5005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-18
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA006340225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist