Provider Demographics
NPI:1316486921
Name:WESSEL, NICOLE (DPT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:WESSEL
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:VENEZIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:408 HIGUERA ST STE 200
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-6135
Mailing Address - Country:US
Mailing Address - Phone:805-788-0805
Mailing Address - Fax:805-788-0845
Practice Address - Street 1:1067 C ST STE 110
Practice Address - Street 2:
Practice Address - City:GALT
Practice Address - State:CA
Practice Address - Zip Code:95632-1758
Practice Address - Country:US
Practice Address - Phone:209-745-5802
Practice Address - Fax:209-745-5574
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-15
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA292352225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA292352OtherCALIFORNIA PT LICENSE