Provider Demographics
NPI:1821672312
Name:WIGHAM, NICOLE (DPT)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:
Last Name:WIGHAM
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:DR
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:LENTINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:99 WASHINGTON ST UNIT 338
Mailing Address - Street 2:
Mailing Address - City:MELROSE
Mailing Address - State:MA
Mailing Address - Zip Code:02176-6088
Mailing Address - Country:US
Mailing Address - Phone:978-478-7793
Mailing Address - Fax:
Practice Address - Street 1:26 MASSACHUSETTS AVE
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:MA
Practice Address - Zip Code:02474-8620
Practice Address - Country:US
Practice Address - Phone:617-828-5617
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-10
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA23901225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist