Provider Demographics
NPI:1659930477
Name:SERGENT, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:SERGENT
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 1:1045 MARYLAND AVE
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21740-7201
Mailing Address - Country:US
Mailing Address - Phone:301-739-5437
Mailing Address - Fax:301-739-7453
Practice Address - Street 1:1045 MARYLAND AVE
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-7201
Practice Address - Country:US
Practice Address - Phone:301-739-5437
Practice Address - Fax:301-739-7453
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-06
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV002138225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist