Provider Demographics
NPI:1457420507
Name:SEVERINO, NICOLE ANN (BS DPT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ANN
Last Name:SEVERINO
Suffix:
Gender:F
Credentials:BS DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19401 40TH AVE W
Mailing Address - Street 2:SUITE 330
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98036-4612
Mailing Address - Country:US
Mailing Address - Phone:425-670-9987
Mailing Address - Fax:425-744-7233
Practice Address - Street 1:19401 40TH AVE W
Practice Address - Street 2:SUITE 330
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98036-4612
Practice Address - Country:US
Practice Address - Phone:425-670-9987
Practice Address - Fax:425-744-7233
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00009953225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8858552Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER