Provider Demographics
NPI:1720689839
Name:CROSS, NICHOLE ALINE (M)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:ALINE
Last Name:CROSS
Suffix:
Gender:F
Credentials:M
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 MAIN ST STE C1
Mailing Address - Street 2:
Mailing Address - City:WAREHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02571-2152
Mailing Address - Country:US
Mailing Address - Phone:586-822-3365
Mailing Address - Fax:
Practice Address - Street 1:45 MAIN ST STE C1
Practice Address - Street 2:
Practice Address - City:WAREHAM
Practice Address - State:MA
Practice Address - Zip Code:02571-2152
Practice Address - Country:US
Practice Address - Phone:508-273-7698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-04
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3346225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3346OtherMASSAGE LICENSE NUMBER