Provider Demographics
NPI:1033320296
Name:FREY, NICOLE MARIE (PTA)
Entity Type:Individual
Prefix:MISS
First Name:NICOLE
Middle Name:MARIE
Last Name:FREY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9302 FIRENZE DR APT 105
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33418-8140
Mailing Address - Country:US
Mailing Address - Phone:614-634-3783
Mailing Address - Fax:
Practice Address - Street 1:3505 LAKE LYNDA DR
Practice Address - Street 2:SUITE 207
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32817-8324
Practice Address - Country:US
Practice Address - Phone:877-896-3660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA20743225200000X
OHPTA06142225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant