Provider Demographics
NPI:1578915724
Name:IENNI, NICHOLAS (PT, DPT)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:IENNI
Suffix:
Gender:M
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 1:7307 E LEWIS AVE
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85257-1426
Mailing Address - Country:US
Mailing Address - Phone:505-553-6262
Mailing Address - Fax:
Practice Address - Street 1:2100 LOUISIANA BLVD NE STE 410
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-5412
Practice Address - Country:US
Practice Address - Phone:505-724-4300
Practice Address - Fax:505-724-4384
Is Sole Proprietor?:No
Enumeration Date:2016-07-11
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPT2023-2062225100000X
AZ31586225100000X
NV3366225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist