Provider Demographics
NPI:1871639476
Name:BESANA, NICOLE (PT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:BESANA
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 1:3654 W ANTHEM WAY
Mailing Address - Street 2:SUITE B102
Mailing Address - City:ANTHEM
Mailing Address - State:AZ
Mailing Address - Zip Code:85086-0455
Mailing Address - Country:US
Mailing Address - Phone:623-551-9706
Mailing Address - Fax:
Practice Address - Street 1:3654 W ANTHEM WAY
Practice Address - Street 2:SUITE B102
Practice Address - City:ANTHEM
Practice Address - State:AZ
Practice Address - Zip Code:85086-0455
Practice Address - Country:US
Practice Address - Phone:623-551-9706
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2008-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8145225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist