Provider Demographics
NPI:1497473524
Name:PACKWOOD, NICOLE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:PACKWOOD
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1329 BARTON RD STE B
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-4419
Mailing Address - Country:US
Mailing Address - Phone:909-255-1694
Mailing Address - Fax:
Practice Address - Street 1:1329 BARTON RD STE B
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-4419
Practice Address - Country:US
Practice Address - Phone:909-255-1694
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-15
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA302481225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist