Provider Demographics
NPI:1952633653
Name:ELLEN, NICOLE M (PT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:ELLEN
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 1:218 E 29TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-8536
Mailing Address - Country:US
Mailing Address - Phone:917-592-8540
Mailing Address - Fax:
Practice Address - Street 1:218 E 29TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-8536
Practice Address - Country:US
Practice Address - Phone:917-592-8540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-04
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014709-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist