Provider Demographics
NPI:1710432455
Name:MILLS, NICOLE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MILLS
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4624 SUMMERDALE DR
Mailing Address - Street 2:
Mailing Address - City:PACE
Mailing Address - State:FL
Mailing Address - Zip Code:32571-1368
Mailing Address - Country:US
Mailing Address - Phone:850-994-3456
Mailing Address - Fax:850-994-3476
Practice Address - Street 1:2140 KINGSLEY AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-5180
Practice Address - Country:US
Practice Address - Phone:904-272-2830
Practice Address - Fax:904-215-3970
Is Sole Proprietor?:No
Enumeration Date:2016-08-23
Last Update Date:2018-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT31709225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist