Basic Information
Provider Information | |||||||||
NPI: | 1679227268 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CALVERT | ||||||||
FirstName: | NICOLE | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | ATC/LAT, CSCS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 850 43RD AVE | ||||||||
Address2: |   | ||||||||
City: | MOLINE | ||||||||
State: | IL | ||||||||
PostalCode: | 612658401 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3097432070 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2109 CEDARWOOD DR STE 100 | ||||||||
Address2: |   | ||||||||
City: | MUSCATINE | ||||||||
State: | IA | ||||||||
PostalCode: | 527612670 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5632886787 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/11/2022 | ||||||||
LastUpdateDate: | 02/11/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/11/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 000944 | IA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
ID Information
ID | Type | State | Issuer | Description | 200938505 | 01 |   | CERTIFIED STRENGTH AND CONDITIONING SPECIALIST (NSCA) | OTHER | 000944 | 01 | IA | STATE OF IOWA DEPT OF PUBLIC HEALTH | OTHER | 2000001771 | 01 |   | BOARD OF CERTIFICATION FOR THE ATHLETIC TRAINER | OTHER |