Provider Demographics
NPI:1629676135
Name:FUKUZAWA, NICOLE ALISON (OTR/L)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ALISON
Last Name:FUKUZAWA
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28515 N NORTH VALLEY PKWY APT 2097
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085-5416
Mailing Address - Country:US
Mailing Address - Phone:714-642-7543
Mailing Address - Fax:
Practice Address - Street 1:4202 N 20TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-5101
Practice Address - Country:US
Practice Address - Phone:714-642-7543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-16
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist