Provider Demographics
NPI:1639648637
Name:HASTIE, NICOLE (PTA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:HASTIE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4536 STATE ROUTE 212
Mailing Address - Street 2:
Mailing Address - City:WILLOW
Mailing Address - State:NY
Mailing Address - Zip Code:12495
Mailing Address - Country:US
Mailing Address - Phone:845-706-2735
Mailing Address - Fax:
Practice Address - Street 1:4536 STATE ROUTE 212
Practice Address - Street 2:
Practice Address - City:WILLOW
Practice Address - State:NY
Practice Address - Zip Code:12495
Practice Address - Country:US
Practice Address - Phone:845-706-2735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-19
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004522-1225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant