Provider Demographics
NPI:1477750040
Name:WIDENER, NORA GANT (LPTA)
Entity Type:Individual
Prefix:MS
First Name:NORA
Middle Name:GANT
Last Name:WIDENER
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5815 BRASCH RD SE
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98367-1119
Mailing Address - Country:US
Mailing Address - Phone:360-876-5317
Mailing Address - Fax:
Practice Address - Street 1:2701 CLARE AVE
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98310-3313
Practice Address - Country:US
Practice Address - Phone:360-377-3951
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306001512225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant