Provider Demographics
NPI:1245920628
Name:CARSON-GILMORE, NIKKIE JEAN (PTA)
Entity type:Individual
Prefix:
First Name:NIKKIE
Middle Name:JEAN
Last Name:CARSON-GILMORE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:NIKI
Other - Middle Name:JEAN
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:885 HOLLY PARK AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA TERESA
Mailing Address - State:NM
Mailing Address - Zip Code:88008-9573
Mailing Address - Country:US
Mailing Address - Phone:615-478-4347
Mailing Address - Fax:
Practice Address - Street 1:1870 NORTHWESTERN DRIVE
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79912
Practice Address - Country:US
Practice Address - Phone:915-877-5800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-10
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKPHYA2909208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation