Provider Demographics
NPI:1215162672
Name:STAVINOHA-PETTIT, NICOLE CHRISTINE (PT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:CHRISTINE
Last Name:STAVINOHA-PETTIT
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 1:800 CRESCENT CENTRE DR STE 300
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37067-7285
Mailing Address - Country:US
Mailing Address - Phone:615-373-1350
Mailing Address - Fax:615-221-9054
Practice Address - Street 1:500 CANYON RIDGE DR
Practice Address - Street 2:SUITE B-150
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78753-1632
Practice Address - Country:US
Practice Address - Phone:512-596-0566
Practice Address - Fax:512-596-0567
Is Sole Proprietor?:No
Enumeration Date:2009-05-28
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1189310225100000X
TX3107446225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8L16209Medicare UPIN
TX8L17785Medicare PIN