Provider Demographics
NPI:1477790707
Name:CLEARY, NICOLE K (PTA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:K
Last Name:CLEARY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:K
Other - Last Name:FRAILING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:PO BOX 50681
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34232-0305
Mailing Address - Country:US
Mailing Address - Phone:941-228-6734
Mailing Address - Fax:941-343-9402
Practice Address - Street 1:13638 2ND AVE NE
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34212-2725
Practice Address - Country:US
Practice Address - Phone:941-228-6734
Practice Address - Fax:941-343-9402
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-08
Last Update Date:2009-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA18759225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant