Provider Demographics
NPI:1679086144
Name:FERNANDEZ, NICOLE CATHLEEN (DPT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:CATHLEEN
Last Name:FERNANDEZ
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 TUMWATER BLVD SE STE 113
Mailing Address - Street 2:
Mailing Address - City:TUMWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98501-6422
Mailing Address - Country:US
Mailing Address - Phone:360-528-3300
Mailing Address - Fax:360-528-8162
Practice Address - Street 1:111 TUMWATER BLVD SE STE 113
Practice Address - Street 2:
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98501-6422
Practice Address - Country:US
Practice Address - Phone:360-528-3300
Practice Address - Fax:360-528-8162
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-07
Last Update Date:2017-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60785817225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist