Provider Demographics
NPI:1801086228
Name:BAIN, NICOLE DIANNE (MSPT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:DIANNE
Last Name:BAIN
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 NEW BRIDGE ST
Mailing Address - Street 2:SUITE 10A
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28540-4739
Mailing Address - Country:US
Mailing Address - Phone:910-347-2212
Mailing Address - Fax:910-347-6003
Practice Address - Street 1:410 NEW BRIDGE ST
Practice Address - Street 2:SUITE 10A
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28540-4739
Practice Address - Country:US
Practice Address - Phone:910-347-2212
Practice Address - Fax:910-347-6003
Is Sole Proprietor?:No
Enumeration Date:2007-08-01
Last Update Date:2007-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC28652251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics