Provider Demographics
NPI:1871851634
Name:GLEASON, NICOLLE LENNA (DPT)
Entity Type:Individual
Prefix:MRS
First Name:NICOLLE
Middle Name:LENNA
Last Name:GLEASON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3403 W LASSEN ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83703-4734
Mailing Address - Country:US
Mailing Address - Phone:208-869-8036
Mailing Address - Fax:
Practice Address - Street 1:5640 E FRANKLIN RD # B
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687-8402
Practice Address - Country:US
Practice Address - Phone:208-484-4640
Practice Address - Fax:208-484-4685
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-30
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-2098225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist