Individual
DEIDRA NICHOLS
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
DPT
Contact information
Practice address
650 N STATE ST, SHELLEY, ID 83274-4900
(208) 782-4744
(208) 906-1554
Mailing address
650 N STATE ST, SHELLEY, ID 83274-4900
(208) 782-4744
(208) 906-1554
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
PT3043
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1225390305
—
ID
Enumeration date
06/13/2012
Last updated
12/31/2019
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