Provider Demographics
NPI:1174849756
Name:NISTICO, GAIL LUCILLE (PHYSICAL THERAPY ASS)
Entity Type:Individual
Prefix:MRS
First Name:GAIL
Middle Name:LUCILLE
Last Name:NISTICO
Suffix:
Gender:F
Credentials:PHYSICAL THERAPY ASS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:219 SEMINARY RD.
Mailing Address - Street 2:
Mailing Address - City:CALLICOON
Mailing Address - State:NY
Mailing Address - Zip Code:12723-5316
Mailing Address - Country:US
Mailing Address - Phone:845-887-1956
Mailing Address - Fax:845-887-1956
Practice Address - Street 1:256 SUNSET LAKE RD
Practice Address - Street 2:SULLIVAN COUNTY ADULT CARE CENTER
Practice Address - City:LIBERTY
Practice Address - State:NY
Practice Address - Zip Code:12754
Practice Address - Country:US
Practice Address - Phone:845-292-5910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-08
Last Update Date:2010-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000169-1225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant