Provider Demographics
NPI:1942878269
Name:NICHOLSON, ROXANE (PT)
Entity Type:Individual
Prefix:
First Name:ROXANE
Middle Name:
Last Name:NICHOLSON
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 1:3303 MINSTEED RD
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:NY
Mailing Address - Zip Code:14505-9408
Mailing Address - Country:US
Mailing Address - Phone:585-966-9166
Mailing Address - Fax:
Practice Address - Street 1:2 COULTER RD
Practice Address - Street 2:
Practice Address - City:CLIFTON SPRINGS
Practice Address - State:NY
Practice Address - Zip Code:14432-1122
Practice Address - Country:US
Practice Address - Phone:315-462-9561
Practice Address - Fax:315-462-3492
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-14
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016024-01261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy