Provider Demographics
NPI:1710390166
Name:BURKETT, NICOLE (PT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:BURKETT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1296 SIMS STREET
Mailing Address - Street 2:SUITE A
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-3850
Mailing Address - Country:US
Mailing Address - Phone:770-297-1700
Mailing Address - Fax:770-297-1702
Practice Address - Street 1:1296 SIMS STREET
Practice Address - Street 2:SUITE A
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3850
Practice Address - Country:US
Practice Address - Phone:770-297-1700
Practice Address - Fax:770-297-1702
Is Sole Proprietor?:No
Enumeration Date:2014-06-03
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT005707225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist