Provider Demographics
NPI:1861075848
Name:VANDERHOOF, NICOLE LYNN (PTA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:LYNN
Last Name:VANDERHOOF
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3915 LAKE NED VILLAGE CIR
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33884-2586
Mailing Address - Country:US
Mailing Address - Phone:727-809-1653
Mailing Address - Fax:
Practice Address - Street 1:400 NORTH LAKE HOWARD DRIVE
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881
Practice Address - Country:US
Practice Address - Phone:863-268-2608
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-28
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA30690225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant