Provider Demographics
NPI:1215341789
Name:RIDDLE, NICOLE (DPT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:RIDDLE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:BREWSTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1137
Mailing Address - Street 2:
Mailing Address - City:ORTING
Mailing Address - State:WA
Mailing Address - Zip Code:98360-1137
Mailing Address - Country:US
Mailing Address - Phone:603-872-0315
Mailing Address - Fax:360-872-0438
Practice Address - Street 1:211 VAN SCOYOC AVE SW
Practice Address - Street 2:
Practice Address - City:ORTING
Practice Address - State:WA
Practice Address - Zip Code:98360-7507
Practice Address - Country:US
Practice Address - Phone:360-872-0315
Practice Address - Fax:360-872-0438
Is Sole Proprietor?:No
Enumeration Date:2014-06-12
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60443508225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist