Provider Demographics
NPI:1891895975
Name:DEGNER, NICOLE (MSPT)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:
Last Name:DEGNER
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9606 BAILEY RD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:CORNELIUS
Mailing Address - State:NC
Mailing Address - Zip Code:28031-6109
Mailing Address - Country:US
Mailing Address - Phone:704-896-8868
Mailing Address - Fax:704-896-7975
Practice Address - Street 1:9606 BAILEY RD
Practice Address - Street 2:SUITE 250
Practice Address - City:CORNELIUS
Practice Address - State:NC
Practice Address - Zip Code:28031-6109
Practice Address - Country:US
Practice Address - Phone:704-896-8868
Practice Address - Fax:704-896-7975
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9139174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1351COtherBLUECROSS BLUESHIELD NC
NC7211540Medicaid
NCD2145OtherMEDCOST