Provider Demographics
NPI:1891024931
Name:MOLTIMORE, NICOLE (PT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MOLTIMORE
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:PO BOX 5521
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32314-5521
Mailing Address - Country:US
Mailing Address - Phone:850-576-5433
Mailing Address - Fax:850-222-5459
Practice Address - Street 1:1533 S MONROE ST
Practice Address - Street 2:SUITE 2
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32301-4331
Practice Address - Country:US
Practice Address - Phone:850-576-5433
Practice Address - Fax:850-222-5459
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-21
Last Update Date:2011-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT19375225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL689991996OtherMEDICAID WAIVER
FLE5946YMedicare Oscar/Certification