Provider Demographics
NPI:1114552064
Name:GENTILEZZA, NICHOLAS
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:GENTILEZZA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:185 GREENFIELD RD
Mailing Address - Street 2:
Mailing Address - City:SCOTT TWP
Mailing Address - State:PA
Mailing Address - Zip Code:18433-7761
Mailing Address - Country:US
Mailing Address - Phone:570-479-0982
Mailing Address - Fax:
Practice Address - Street 1:185 GREENFIELD RD
Practice Address - Street 2:
Practice Address - City:SCOTT TWP
Practice Address - State:PA
Practice Address - Zip Code:18433-7761
Practice Address - Country:US
Practice Address - Phone:570-479-0982
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-10
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATEI003421225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant