Provider Demographics
NPI:1629135371
Name:DERUE, NICOLE (PT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:DERUE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:573 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CENTRAL SQUARE
Mailing Address - State:NY
Mailing Address - Zip Code:13036-9785
Mailing Address - Country:US
Mailing Address - Phone:315-676-3826
Mailing Address - Fax:315-676-3402
Practice Address - Street 1:573 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CENTRAL SQUARE
Practice Address - State:NY
Practice Address - Zip Code:13036-9785
Practice Address - Country:US
Practice Address - Phone:315-676-3826
Practice Address - Fax:315-676-3402
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0281751225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0281751OtherLICENSE
NYRB5106Medicare PIN