Provider Demographics
NPI:1205025343
Name:JOHNSON, NICOLE D (DPT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:D
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 COURTNEY TRACE DR
Mailing Address - Street 2:APT 201
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3248 LITHIA PINECREST RD STE 102
Practice Address - Street 2:
Practice Address - City:VALRICO
Practice Address - State:FL
Practice Address - Zip Code:33596-5682
Practice Address - Country:US
Practice Address - Phone:813-662-1366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-15
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT.011937225100000X
FL25546225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist