Basic Information
| Provider Information | |||||||||
| NPI: | 1275021164 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NICKERSON | ||||||||
| FirstName: | KRISTINA | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | COTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4218 US HIGHWAY 80 E APT 2067 | ||||||||
| Address2: | |||||||||
| City: | MESQUITE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 751491173 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2542051171 | ||||||||
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| Practice Location | |||||||||
| Address1: | 930 W CENTERVILLE RD STE C | ||||||||
| Address2: | |||||||||
| City: | GARLAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750415854 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9723037021 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2018 | ||||||||
| LastUpdateDate: | 04/25/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 215045 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.