Provider Demographics
NPI:1538264486
Name:NISHI-GORMELY, MARILYN J (PT)
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:J
Last Name:NISHI-GORMELY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:14520 MONO WAY
Mailing Address - Street 2:SUITE 130
Mailing Address - City:SONORA
Mailing Address - State:CA
Mailing Address - Zip Code:95370-9500
Mailing Address - Country:US
Mailing Address - Phone:209-533-1273
Mailing Address - Fax:209-533-1382
Practice Address - Street 1:14520 MONO WAY
Practice Address - Street 2:STE 130
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-9500
Practice Address - Country:US
Practice Address - Phone:209-533-1273
Practice Address - Fax:209-533-1382
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT97780225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00064243OtherRAILROAD MEDICARE
CAZZZ39907ZOtherBLUE SHIELD
CAZZZ39907ZOtherBLUE SHIELD