Basic Information
| Provider Information | |||||||||
| NPI: | 1740815133 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEMERY | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | MICHELLE | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | W5607 WILLOW ROAD NUMBER 3.5 | ||||||||
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| City: | MENOMINEE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 498589101 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 831 PINE BEACH RD | ||||||||
| Address2: | |||||||||
| City: | MARINETTE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 541434225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7157320155 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2020 | ||||||||
| LastUpdateDate: | 03/06/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 2776-19 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.