Provider Demographics
NPI:1871923649
Name:STINES, NICOLE A (PT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:A
Last Name:STINES
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:A
Other - Last Name:MOKLESTAD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:204 N 4TH AVE E
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:IA
Mailing Address - Zip Code:50208-3135
Mailing Address - Country:US
Mailing Address - Phone:641-792-1273
Mailing Address - Fax:641-791-4852
Practice Address - Street 1:300 N 4TH AVE E
Practice Address - Street 2:SUITE G
Practice Address - City:NEWTON
Practice Address - State:IA
Practice Address - Zip Code:50208-3155
Practice Address - Country:US
Practice Address - Phone:641-792-1273
Practice Address - Fax:641-791-4852
Is Sole Proprietor?:No
Enumeration Date:2013-11-15
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA005228225100000X
NC14798225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC14798OtherNC BOARD OF PHYSICAL THERAPY
IA005228OtherSTATE LICENSE