Provider Demographics
NPI:1700805728
Name:NICHTING, HEATHER RENAE
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:RENAE
Last Name:NICHTING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3819 MONROE AVE
Mailing Address - Street 2:
Mailing Address - City:PITTSFORD
Mailing Address - State:NY
Mailing Address - Zip Code:14534-1336
Mailing Address - Country:US
Mailing Address - Phone:585-586-3819
Mailing Address - Fax:866-463-1081
Practice Address - Street 1:3819 MONROE AVE
Practice Address - Street 2:
Practice Address - City:PITTSFORD
Practice Address - State:NY
Practice Address - Zip Code:14534-1336
Practice Address - Country:US
Practice Address - Phone:585-586-3819
Practice Address - Fax:866-463-1081
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2012-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026504-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00355344Medicaid
NY1142154OtherCAQH
NY00355344Medicaid