Provider Demographics
NPI:1538749817
Name:FONSECA, NICOLETTE (PT, DPT)
Entity type:Individual
Prefix:
First Name:NICOLETTE
Middle Name:
Last Name:FONSECA
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2976 IROQUOIS DR
Mailing Address - Street 2:
Mailing Address - City:THOMPSONS STATION
Mailing Address - State:TN
Mailing Address - Zip Code:37179-5022
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:913 11TH ST SE STE 2
Practice Address - Street 2:
Practice Address - City:BANDON
Practice Address - State:OR
Practice Address - Zip Code:97411-9168
Practice Address - Country:US
Practice Address - Phone:541-347-4314
Practice Address - Fax:541-347-8006
Is Sole Proprietor?:No
Enumeration Date:2021-04-12
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-06089225100000X
TN11972225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist