Provider Demographics
NPI:1679932891
Name:OWENS, NICOLETTE (PT, DPT, CERT DN)
Entity Type:Individual
Prefix:
First Name:NICOLETTE
Middle Name:
Last Name:OWENS
Suffix:
Gender:F
Credentials:PT, DPT, CERT DN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11209 N TATUM BLVD STE B120
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-3091
Mailing Address - Country:US
Mailing Address - Phone:602-795-8441
Mailing Address - Fax:
Practice Address - Street 1:11209 N TATUM BLVD STE B120
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-3091
Practice Address - Country:US
Practice Address - Phone:602-795-8441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-16
Last Update Date:2019-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ12057225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist