Provider Demographics
NPI:1578933040
Name:DECRISTOFORO, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:DECRISTOFORO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7625 MESA COLLEGE DR STE 101A
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-5343
Mailing Address - Country:US
Mailing Address - Phone:858-277-1586
Mailing Address - Fax:858-277-1828
Practice Address - Street 1:73 VALLEY RD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:RI
Practice Address - Zip Code:02842-5234
Practice Address - Country:US
Practice Address - Phone:401-433-4172
Practice Address - Fax:014-330-6124
Is Sole Proprietor?:No
Enumeration Date:2015-09-28
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT299778225100000X
RIPT02823225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist