Provider Demographics
NPI:1285188052
Name:NICKERSON, ELEXA
Entity Type:Individual
Prefix:
First Name:ELEXA
Middle Name:
Last Name:NICKERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:98 POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:OLD TOWN
Mailing Address - State:ME
Mailing Address - Zip Code:04468-5901
Mailing Address - Country:US
Mailing Address - Phone:207-745-4955
Mailing Address - Fax:
Practice Address - Street 1:117 BENNOCH RD
Practice Address - Street 2:
Practice Address - City:ORONO
Practice Address - State:ME
Practice Address - Zip Code:04473-3620
Practice Address - Country:US
Practice Address - Phone:207-866-4914
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-10
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA4696225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant