Basic Information
Provider Information
NPI: 1003148594
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: NUCKOLS
FirstName: KRISTIN
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: OTR/L
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 102 DONNA PL
Address2:  
City: CARY
State: NC
PostalCode: 275135303
CountryCode: US
TelephoneNumber: 5402712902
FaxNumber: 5402712902
Practice Location
Address1: 102 DONNA PL
Address2:  
City: CARY
State: NC
PostalCode: 275135303
CountryCode: US
TelephoneNumber: 5402712902
FaxNumber: 5402712902
Other Information
ProviderEnumerationDate: 02/08/2010
LastUpdateDate: 12/30/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
225X00000X0119004751VAY Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist 

No ID Information.


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