Provider Demographics
NPI:1275289365
Name:FALLON, NICOLE ELIZABETH (MS, LAT, ATC)
Entity Type:Individual
Prefix:MISS
First Name:NICOLE
Middle Name:ELIZABETH
Last Name:FALLON
Suffix:
Gender:F
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:622 DRAKE AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLESEX
Mailing Address - State:NJ
Mailing Address - Zip Code:08846-2438
Mailing Address - Country:US
Mailing Address - Phone:732-640-3206
Mailing Address - Fax:
Practice Address - Street 1:238 VAN BUREN ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07105-2512
Practice Address - Country:US
Practice Address - Phone:732-640-3206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-27
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MT003192002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer