Provider Demographics
NPI:1376963983
Name:STALLWORTH, NICOLETTE ANNETTE (ATC)
Entity Type:Individual
Prefix:MISS
First Name:NICOLETTE
Middle Name:ANNETTE
Last Name:STALLWORTH
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1951 NW SOUTH RIVER DR
Mailing Address - Street 2:APT 1710
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33125-2784
Mailing Address - Country:US
Mailing Address - Phone:248-943-6637
Mailing Address - Fax:
Practice Address - Street 1:1200 NW 6TH AVE
Practice Address - Street 2:ROOM 0028
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-2409
Practice Address - Country:US
Practice Address - Phone:305-324-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-22
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL32992255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer