Provider Demographics
NPI:1124211941
Name:BUURMA, NICOLE J (DPT)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:J
Last Name:BUURMA
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:J
Other - Last Name:VANDERWIELE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:1824 FRONT ST STE A
Mailing Address - Street 2:
Mailing Address - City:LYNDEN
Mailing Address - State:WA
Mailing Address - Zip Code:98264-1729
Mailing Address - Country:US
Mailing Address - Phone:360-354-0585
Mailing Address - Fax:360-354-1098
Practice Address - Street 1:1824 FRONT STREET
Practice Address - Street 2:STE A
Practice Address - City:LYNDEN
Practice Address - State:WA
Practice Address - Zip Code:98264-8708
Practice Address - Country:US
Practice Address - Phone:360-354-0585
Practice Address - Fax:360-354-1098
Is Sole Proprietor?:No
Enumeration Date:2007-08-24
Last Update Date:2017-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070015873225100000X
WAPT60011687225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCJ4383OtherR.R. MEDICARE GROUP #
WAGAB14760OtherMEDICARE GROUP NUMBER
IL1619908OtherBCBS IL GROUP NUMBER
IL200852OtherMEDICARE GROUP#
IL568080OtherMEDICARE GROUP NUMBER
IL202542OtherMEDICARE GROUP #
IL567770OtherMEDICARE GROUP #
IL1623066OtherBCBS PROVIDER #
IL367885100OtherUS DEPT OF LABOR
IL568080OtherMEDICARE GROUP NUMBER
IL200852OtherMEDICARE GROUP#