Basic Information
| Provider Information | |||||||||
| NPI: | 1265617377 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NETTLES | ||||||||
| FirstName: | CICILEY | ||||||||
| MiddleName: | KAY | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | COTAL | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RUARK | ||||||||
| OtherFirstName: | CICILEY | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 444 | ||||||||
| Address2: | |||||||||
| City: | THERMOPOLIS | ||||||||
| State: | WY | ||||||||
| PostalCode: | 82443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3079218435 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1901 HOWELL AVE | ||||||||
| Address2: | |||||||||
| City: | WORLAND | ||||||||
| State: | WY | ||||||||
| PostalCode: | 82401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073474285 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2008 | ||||||||
| LastUpdateDate: | 01/08/2008 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 508 | WY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.