Provider Demographics
NPI:1902056740
Name:NICHOLSON, WANDA KAY AGENT (PT)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:KAY AGENT
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:166 SEQUOIAH LN
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37760-3428
Mailing Address - Country:US
Mailing Address - Phone:865-475-9967
Mailing Address - Fax:
Practice Address - Street 1:283 W BROADWAY BLVD
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37760-2302
Practice Address - Country:US
Practice Address - Phone:865-475-9967
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-29
Last Update Date:2008-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPT564225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist