Provider Demographics
NPI:1295192284
Name:FRAZEE-STEWART, NICOLE (PTA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:FRAZEE-STEWART
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:PO BOX 1609
Mailing Address - Street 2:
Mailing Address - City:CALLAHAN
Mailing Address - State:FL
Mailing Address - Zip Code:32011-1609
Mailing Address - Country:US
Mailing Address - Phone:904-277-4449
Mailing Address - Fax:904-277-4177
Practice Address - Street 1:1885 S 14TH ST
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-3033
Practice Address - Country:US
Practice Address - Phone:904-277-4449
Practice Address - Fax:904-277-4177
Is Sole Proprietor?:No
Enumeration Date:2016-01-21
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA26233225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY927QOtherFLORIDA BLUE
FLDO0550OtherMEDICARE RAILROAD
FLY907MOtherFLORIDA BLUE
FLAM305Medicare PIN