Provider Demographics
NPI:1326209214
Name:DESJARDINS, NICOLE DENISE (MSPT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:DENISE
Last Name:DESJARDINS
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 CARON ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-6446
Mailing Address - Country:US
Mailing Address - Phone:207-795-6330
Mailing Address - Fax:
Practice Address - Street 1:440 MINOT AVE
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:ME
Practice Address - Zip Code:04210-4332
Practice Address - Country:US
Practice Address - Phone:207-784-3573
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-23
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT28772251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics