Provider Demographics
NPI:1033939244
Name:VASQUEZ, NICOLE DOMINIQUE JALANDONI
Entity type:Individual
Prefix:
First Name:NICOLE DOMINIQUE
Middle Name:JALANDONI
Last Name:VASQUEZ
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 1:6462 STEAMER DR SE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98513-6230
Mailing Address - Country:US
Mailing Address - Phone:564-225-7309
Mailing Address - Fax:
Practice Address - Street 1:1445 GALAXY DR NE STE 301
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98516-4754
Practice Address - Country:US
Practice Address - Phone:360-456-1444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-12
Last Update Date:2024-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT61432108225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist