Provider Demographics
NPI:1801435763
Name:ENGSTROM, NICOLE G
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:G
Last Name:ENGSTROM
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 1:50 ROUTE 46 E
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN LAKES
Mailing Address - State:NJ
Mailing Address - Zip Code:07046-1623
Mailing Address - Country:US
Mailing Address - Phone:973-402-1600
Mailing Address - Fax:973-402-1770
Practice Address - Street 1:50 ROUTE 46 E
Practice Address - Street 2:
Practice Address - City:MOUNTAIN LAKES
Practice Address - State:NJ
Practice Address - Zip Code:07046-1623
Practice Address - Country:US
Practice Address - Phone:973-402-1600
Practice Address - Fax:973-402-1770
Is Sole Proprietor?:No
Enumeration Date:2019-12-24
Last Update Date:2019-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01910400225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist