Provider Demographics
NPI:1073034252
Name:THAXTON, NICOLE LYNN (PT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LYNN
Last Name:THAXTON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:FALDYN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2222
Mailing Address - Fax:
Practice Address - Street 1:701 TUSCAN DR
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75039-4133
Practice Address - Country:US
Practice Address - Phone:214-727-8820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-28
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1290816225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist