Provider Demographics
NPI:1851772883
Name:FABRICATORE, NICOLE (PTA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:FABRICATORE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:519 2ND ST
Mailing Address - Street 2:
Mailing Address - City:DUNMORE
Mailing Address - State:PA
Mailing Address - Zip Code:18512-3001
Mailing Address - Country:US
Mailing Address - Phone:570-561-8748
Mailing Address - Fax:
Practice Address - Street 1:519 2ND ST
Practice Address - Street 2:
Practice Address - City:DUNMORE
Practice Address - State:PA
Practice Address - Zip Code:18512-3001
Practice Address - Country:US
Practice Address - Phone:570-561-8748
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-16
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATEI001590225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant