Provider Demographics
NPI:1245661164
Name:BASHAM, NICOLE (DPT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:BASHAM
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 1:8557 DIAMOND OAK WAY
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95624-1749
Mailing Address - Country:US
Mailing Address - Phone:858-735-1753
Mailing Address - Fax:
Practice Address - Street 1:10200 TRINITY PKWY STE 205
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95219-7288
Practice Address - Country:US
Practice Address - Phone:209-451-3920
Practice Address - Fax:209-451-3902
Is Sole Proprietor?:No
Enumeration Date:2013-12-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60408454225100000X
CA41238225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist