Provider Demographics
NPI:1174802987
Name:BOVKOON, NICOLE ANNE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:ANNE
Last Name:BOVKOON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:ANNE
Other - Last Name:SINELE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:P.O. DRAWER 2109
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72811-2109
Mailing Address - Country:US
Mailing Address - Phone:479-967-2322
Mailing Address - Fax:479-967-2876
Practice Address - Street 1:1301 RUSSELL RD
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72802-4320
Practice Address - Country:US
Practice Address - Phone:479-967-2316
Practice Address - Fax:479-967-3639
Is Sole Proprietor?:No
Enumeration Date:2011-08-10
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARO-T1144225X00000X
AROTR2456225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR188618721Medicaid