Provider Demographics
NPI:1699166843
Name:HARTLEY, NICHOLAS COLE (DPT)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:COLE
Last Name:HARTLEY
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:441 S WHITLEY DR
Mailing Address - Street 2:
Mailing Address - City:FRUITLAND
Mailing Address - State:ID
Mailing Address - Zip Code:83619-2542
Mailing Address - Country:US
Mailing Address - Phone:208-452-7197
Mailing Address - Fax:208-452-4811
Practice Address - Street 1:441 S WHITLEY DR
Practice Address - Street 2:
Practice Address - City:FRUITLAND
Practice Address - State:ID
Practice Address - Zip Code:83619-2542
Practice Address - Country:US
Practice Address - Phone:208-452-7197
Practice Address - Fax:208-452-4811
Is Sole Proprietor?:No
Enumeration Date:2015-02-10
Last Update Date:2017-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-3815225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1699166843Medicaid