Provider Demographics
NPI:1669964243
Name:BRISTOW, NICOLE D (PT, DPT)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:D
Last Name:BRISTOW
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:D
Other - Last Name:HUNT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:1201 E MICHIGAN AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-1853
Mailing Address - Country:US
Mailing Address - Phone:517-205-7633
Mailing Address - Fax:517-205-7634
Practice Address - Street 1:1201 E MICHIGAN AVE STE 300
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1853
Practice Address - Country:US
Practice Address - Phone:517-205-7633
Practice Address - Fax:517-205-7634
Is Sole Proprietor?:No
Enumeration Date:2018-05-31
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501015343225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist