Provider Demographics
NPI:1386939031
Name:STAVALE, NICOLE M (PT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:STAVALE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:M
Other - Last Name:MARIMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:55 SOUTHWEST DR
Mailing Address - Street 2:
Mailing Address - City:SEDONA
Mailing Address - State:AZ
Mailing Address - Zip Code:86336-3723
Mailing Address - Country:US
Mailing Address - Phone:928-282-5050
Mailing Address - Fax:928-282-5945
Practice Address - Street 1:55 SOUTHWEST DR
Practice Address - Street 2:
Practice Address - City:SEDONA
Practice Address - State:AZ
Practice Address - Zip Code:86336-3723
Practice Address - Country:US
Practice Address - Phone:928-282-5050
Practice Address - Fax:928-282-5945
Is Sole Proprietor?:No
Enumeration Date:2011-06-10
Last Update Date:2014-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ166357Medicare PIN
ORR160060Medicare PIN