Provider Demographics
NPI:1326353327
Name:PANICO, NICHOLE J
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:J
Last Name:PANICO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICHOLE
Other - Middle Name:J
Other - Last Name:TIEGEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:520 JEFFERSON AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:JEANNETTE
Mailing Address - State:PA
Mailing Address - Zip Code:15644-2538
Mailing Address - Country:US
Mailing Address - Phone:724-850-6933
Mailing Address - Fax:724-522-4002
Practice Address - Street 1:117 W WELLINGTON ALY
Practice Address - Street 2:
Practice Address - City:LIGONIER
Practice Address - State:PA
Practice Address - Zip Code:15658-6201
Practice Address - Country:US
Practice Address - Phone:724-995-8815
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-13
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT024725225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist