Provider Demographics
NPI:1376502856
Name:REDICK, NANCY (PT)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:REDICK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 WEST AVE
Mailing Address - Street 2:
Mailing Address - City:LE ROY
Mailing Address - State:NY
Mailing Address - Zip Code:14482-1381
Mailing Address - Country:US
Mailing Address - Phone:315-524-9735
Mailing Address - Fax:315-524-4423
Practice Address - Street 1:1272 RIDGE RD
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:NY
Practice Address - Zip Code:14519-9101
Practice Address - Country:US
Practice Address - Phone:315-524-9735
Practice Address - Fax:315-524-4423
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025864-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY145096FTOtherPREF CARE
NY7071570OtherAENTA ID #
NYP010025864OtherBLUE'S PROVIDER #
NYP010025864OtherPOMCO
NY161578875OtherCOMM/PRI /NF/WC/ INS #
NYRA2639Medicare UPIN