Provider Demographics
NPI:1609901438
Name:GROGAN, NICOLE A (PT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:A
Last Name:GROGAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:A
Other - Last Name:MILES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:2129 W NEW HAVEN AVE
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-3875
Mailing Address - Country:US
Mailing Address - Phone:800-853-4570
Mailing Address - Fax:866-746-1525
Practice Address - Street 1:2129 W NEW HAVEN AVE
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-3875
Practice Address - Country:US
Practice Address - Phone:800-853-4570
Practice Address - Fax:866-746-1525
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT0007836225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT0007836OtherLICENSE