Provider Demographics
NPI:1194851626
Name:REDGATE, NANCY LEE (PT)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:LEE
Last Name:REDGATE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:NANCY
Other - Middle Name:LEE
Other - Last Name:MILES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 4501
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91359-1501
Mailing Address - Country:US
Mailing Address - Phone:805-469-4561
Mailing Address - Fax:
Practice Address - Street 1:1690 BLACKWALL DR
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93063-3208
Practice Address - Country:US
Practice Address - Phone:805-469-4561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT11278225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist