Provider Demographics
NPI:1285640953
Name:SUMMERLIN, NICOLE LEAH (PT)
Entity type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:LEAH
Last Name:SUMMERLIN
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:PO BOX 80217
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85060-0217
Mailing Address - Country:US
Mailing Address - Phone:602-385-2115
Mailing Address - Fax:480-418-3323
Practice Address - Street 1:3033 N 44TH ST STE 100
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85018-7227
Practice Address - Country:US
Practice Address - Phone:602-631-3161
Practice Address - Fax:602-631-3162
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6795225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ3Z3932OtherHEALTH NET
AZ3Z3932OtherHEALTH NET
AZP00842041Medicare PIN