Provider Demographics
NPI:1932657483
Name:LARAMIE, NICOLE ALEXANDRIA
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ALEXANDRIA
Last Name:LARAMIE
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 1:4931 E PIONEER ST
Mailing Address - Street 2:
Mailing Address - City:APACHE JUNCTION
Mailing Address - State:AZ
Mailing Address - Zip Code:85119-9581
Mailing Address - Country:US
Mailing Address - Phone:602-751-6819
Mailing Address - Fax:
Practice Address - Street 1:6820 S KINGS RANCH RD STE 131
Practice Address - Street 2:
Practice Address - City:GOLD CANYON
Practice Address - State:AZ
Practice Address - Zip Code:85118-2959
Practice Address - Country:US
Practice Address - Phone:480-983-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-13
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ12496APTA225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant