Provider Demographics
NPI:1508956996
Name:TRISTRAM, NICOLE CHINGOON (PT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:CHINGOON
Last Name:TRISTRAM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:PREMIERE
Other - Middle Name:
Other - Last Name:PILATES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:4057 SEMINOLE POINT CT
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-5851
Mailing Address - Country:US
Mailing Address - Phone:904-797-8328
Mailing Address - Fax:
Practice Address - Street 1:4057 SEMINOLE POINT CT
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5851
Practice Address - Country:US
Practice Address - Phone:904-315-0667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2009-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 17260225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL887725400Medicaid
FLY7609YMedicare PIN