Provider Demographics
NPI:1164767851
Name:LARRALDE, NANCY (PT)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:LARRALDE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:338 JOSEPH DR
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-5634
Mailing Address - Country:US
Mailing Address - Phone:570-714-3049
Mailing Address - Fax:
Practice Address - Street 1:209 ROBERTS ROAD
Practice Address - Street 2:UNITED METHODIST HOME WESLEY VILLAGE
Practice Address - City:PITTSTON
Practice Address - State:PA
Practice Address - Zip Code:18640
Practice Address - Country:US
Practice Address - Phone:570-655-2891
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-06
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT005628L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist