Provider Demographics
NPI:1073035200
Name:SHIMOTAKE, NICOLE JUN (ATC)
Entity Type:Individual
Prefix:MISS
First Name:NICOLE
Middle Name:JUN
Last Name:SHIMOTAKE
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1470 SUNSET LOOP
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CA
Mailing Address - Zip Code:94549-6045
Mailing Address - Country:US
Mailing Address - Phone:925-817-7404
Mailing Address - Fax:
Practice Address - Street 1:1470 SUNSET LOOP
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CA
Practice Address - Zip Code:94549-6045
Practice Address - Country:US
Practice Address - Phone:925-817-7404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer