Provider Demographics
NPI:1215416482
Name:CALDERHEAD, NICHOLE (PT)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:
Last Name:CALDERHEAD
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 1:19631 EXCEPTIONAL TRL
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55024-8666
Mailing Address - Country:US
Mailing Address - Phone:330-224-2664
Mailing Address - Fax:
Practice Address - Street 1:9311 S ORANGE BLOSSOM TRL
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32837-8301
Practice Address - Country:US
Practice Address - Phone:407-858-0455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-08
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL33679225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist