Provider Demographics
NPI:1609633031
Name:CHRISTOFFERSON, NICOLE AMINA
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:AMINA
Last Name:CHRISTOFFERSON
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 1:3133 SONOMA AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-6859
Mailing Address - Country:US
Mailing Address - Phone:515-520-7523
Mailing Address - Fax:
Practice Address - Street 1:1400 N DUTTON AVE STE 1
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-7120
Practice Address - Country:US
Practice Address - Phone:707-523-2848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-04
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53164225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant