Provider Demographics
NPI:1669844973
Name:SPRAGUE, NICOLE M
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:SPRAGUE
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 1:6581 MOROCCO STREET
Mailing Address - Street 2:
Mailing Address - City:ALTA LOMA
Mailing Address - State:CA
Mailing Address - Zip Code:91737
Mailing Address - Country:US
Mailing Address - Phone:909-234-0247
Mailing Address - Fax:951-698-0062
Practice Address - Street 1:6581 MOROCCO ST
Practice Address - Street 2:
Practice Address - City:ALTA LOMA
Practice Address - State:CA
Practice Address - Zip Code:91737-4317
Practice Address - Country:US
Practice Address - Phone:909-234-0247
Practice Address - Fax:951-698-0062
Is Sole Proprietor?:No
Enumeration Date:2015-10-26
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35693227800000X, 2278P1005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2278P1005XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, CertifiedPulmonary Rehabilitation
No227800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Certified
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA054550Medicare PIN