Provider Demographics
NPI:1225543119
Name:TAN, NICOLE PINEDA (PTA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:PINEDA
Last Name:TAN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2023 OTTERBEIN AVE
Mailing Address - Street 2:
Mailing Address - City:ROWLAND HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:91748-3950
Mailing Address - Country:US
Mailing Address - Phone:626-251-0315
Mailing Address - Fax:
Practice Address - Street 1:1101 S ANAHEIM BLVD
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92805-5811
Practice Address - Country:US
Practice Address - Phone:714-929-1750
Practice Address - Fax:714-937-1966
Is Sole Proprietor?:No
Enumeration Date:2017-12-13
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPTA49028225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant