Basic Information
| Provider Information | |||||||||
| NPI: | 1720795743 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | ENSLEN | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | R | ||||||||
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| Mailing Information | |||||||||
| Address1: | 746 WOODLAWN ST | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 467502352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2603884005 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1720 ALBER ST | ||||||||
| Address2: | |||||||||
| City: | WABASH | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469921015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2605634112 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2022 | ||||||||
| LastUpdateDate: | 10/31/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 32002933A | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant | 224Z00000X | 32002933A | IN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | 32002933A | 01 | INDIVIDUAL | OTHER |