Provider Demographics
NPI:1679757660
Name:MADONIA, NICOLE CONSTANCE (PT, ATC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:CONSTANCE
Last Name:MADONIA
Suffix:
Gender:F
Credentials:PT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17612 RAINGLEN LN
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92649-4728
Mailing Address - Country:US
Mailing Address - Phone:714-232-9061
Mailing Address - Fax:
Practice Address - Street 1:1635 S CENTER ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92704-4111
Practice Address - Country:US
Practice Address - Phone:714-430-6206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-26
Last Update Date:2007-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34292225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist