Basic Information
| Provider Information | |||||||||
| NPI: | 1811302383 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HANEY | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OTR/L | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | OROS | ||||||||
| OtherFirstName: | NICOLE | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | OTR/L | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 109 WIND HAVEN DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | NICHOLASVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403568010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592242273 | ||||||||
| FaxNumber: | 8592244675 | ||||||||
| Practice Location | |||||||||
| Address1: | 109 WIND HAVEN DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | NICHOLASVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40356 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592242273 | ||||||||
| FaxNumber: | 8592244675 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2014 | ||||||||
| LastUpdateDate: | 04/26/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225XP0200X | R5802 | KY | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Pediatrics | 225X00000X | 135802 | KY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 000000880081 | 01 | KY | ANTHEM | OTHER |