Provider Demographics
NPI:1205915238
Name:NIEMIEC, NICOLE ELLIS (PT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:ELLIS
Last Name:NIEMIEC
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 1:270 HUTTLESTON AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRHAVEN
Mailing Address - State:MA
Mailing Address - Zip Code:02719-1605
Mailing Address - Country:US
Mailing Address - Phone:508-997-9100
Mailing Address - Fax:508-993-5854
Practice Address - Street 1:270 HUTTLESTON AVE
Practice Address - Street 2:
Practice Address - City:FAIRHAVEN
Practice Address - State:MA
Practice Address - Zip Code:02719-1605
Practice Address - Country:US
Practice Address - Phone:508-997-9100
Practice Address - Fax:508-993-5854
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2008-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPT 15976225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA5437781OtherCIGNA
MA27759-4OtherBCBS RI
Y6932202OtherPTAN
MAY68325OtherBCBS
MA41177-1OtherRI BLUE CHIP
MA478985OtherTUFTS
MA5437781OtherCIGNA