Provider Demographics
NPI:1285127571
Name:MACDONALD, NICOLE TODISCO (PT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:TODISCO
Last Name:MACDONALD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:ANN
Other - Last Name:TODISCO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1645 NE SHEPARD RD
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-4164
Mailing Address - Country:US
Mailing Address - Phone:802-318-2254
Mailing Address - Fax:
Practice Address - Street 1:345 SW CYBER DR STE 104
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-1045
Practice Address - Country:US
Practice Address - Phone:802-318-2254
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-11
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR62809225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500744539Medicaid