Provider Demographics
NPI:1871092874
Name:NICKEL, SELENA
Entity type:Individual
Prefix:
First Name:SELENA
Middle Name:
Last Name:NICKEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 CARLSON AVE
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-1914
Mailing Address - Country:US
Mailing Address - Phone:208-557-3516
Mailing Address - Fax:208-549-7575
Practice Address - Street 1:2450 E 25TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7577
Practice Address - Country:US
Practice Address - Phone:208-656-5858
Practice Address - Fax:205-549-7575
Is Sole Proprietor?:No
Enumeration Date:2018-02-05
Last Update Date:2018-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist