Provider Demographics
NPI:1053514802
Name:WADE, NICOLE (PT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:WADE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9987
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304-0067
Mailing Address - Country:US
Mailing Address - Phone:703-672-1883
Mailing Address - Fax:
Practice Address - Street 1:8001 LYNBROOK DR
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20814-4642
Practice Address - Country:US
Practice Address - Phone:240-740-5500
Practice Address - Fax:301-657-4971
Is Sole Proprietor?:No
Enumeration Date:2007-06-08
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD18549225100000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist