Provider Demographics
NPI:1699504357
Name:SEBASTIAN, NIKKI ELLINE
Entity type:Individual
Prefix:
First Name:NIKKI ELLINE
Middle Name:
Last Name:SEBASTIAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40-06 68TH STREET
Mailing Address - Street 2:UNIT 3A
Mailing Address - City:WOODSIDE, QUEENS
Mailing Address - State:NY
Mailing Address - Zip Code:11377
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5630 MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385-4736
Practice Address - Country:US
Practice Address - Phone:718-400-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-31
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047618225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist