Provider Demographics
NPI:1245241264
Name:MASTRANTONI, NICOLE R (DPT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:R
Last Name:MASTRANTONI
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 PENCO RD
Mailing Address - Street 2:
Mailing Address - City:WEIRTON
Mailing Address - State:WV
Mailing Address - Zip Code:26062
Mailing Address - Country:US
Mailing Address - Phone:304-723-3780
Mailing Address - Fax:304-723-4110
Practice Address - Street 1:414 PENCO RD
Practice Address - Street 2:
Practice Address - City:WEIRTON
Practice Address - State:WV
Practice Address - Zip Code:26062
Practice Address - Country:US
Practice Address - Phone:304-723-3780
Practice Address - Fax:304-723-4110
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV002101225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810004837Medicaid
WV3810004837Medicaid
WVMA4154103Medicare PIN
WVMA4154102Medicare PIN