Provider Demographics
NPI:1649068834
Name:WILLIAMS, NICOLE LYNNE (PTA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:LYNNE
Last Name:WILLIAMS
Suffix:
Gender:
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 SUFFOLK DR
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-2584
Mailing Address - Country:US
Mailing Address - Phone:214-883-6712
Mailing Address - Fax:
Practice Address - Street 1:7929 BROOKRIVER DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75247-4900
Practice Address - Country:US
Practice Address - Phone:214-389-6663
Practice Address - Fax:214-351-6453
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-28
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2074490225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty