Provider Demographics
NPI:1578099214
Name:ANDERSON, NICOLE A (DPT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:A
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 NEWPORT CENTER DR STE 502
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7520
Mailing Address - Country:US
Mailing Address - Phone:949-529-1184
Mailing Address - Fax:949-861-9990
Practice Address - Street 1:260 NEWPORT CENTER DR STE 502
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7520
Practice Address - Country:US
Practice Address - Phone:949-529-1184
Practice Address - Fax:949-861-9990
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-01
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT292726225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist